Aging Asia's menopause challenge

For International Women’s Day 2024, Nikkei Asia examines the economic toll of female reproductive aging in East Asia, and spotlights the activists working to curb it.

TOKYO/SINGAPORE/SEOUL – Around 12 p.m. on a stifling August day in 2022, Sanae Suzuki woke up to the sound of car horns. Gathering her bearings, she became dimly aware they were directed toward her – or rather, her car. Then she realized she was driving it.

Straddling the middle of a busy intersection in her hometown of Miyazaki, southern Japan, Suzuki slowly put together the pieces. She had left work only a few minutes before, feeling unwell and fearing she had heat exhaustion. It soon hit her that something more serious was afoot.

“I must have lost consciousness just as I was turning at the traffic lights,” Suzuki told Nikkei Asia. “All I remember is, when I came round, the car behind was honking at me. … I feared for my life. It was terrifying.”

Thoroughly shaken by what could have been a serious crash, the 51-year-old Suzuki somehow drove herself to a nearby hospital. After multiple tests, she was referred to an obstetrics and gynecology clinic. There, the doctor informed her she was approaching menopause – the point at which a woman’s reproductive organs, the ovaries, stop producing hormones and menstruation ceases, marking the end of her reproductive years.

According to the World Economic Forum, over 450 million women experience menopause-related symptoms globally.

Suzuki had been dealing with heart palpitations, shortness of breath and occasional loss of consciousness for months, but these were not due to Japan’s aggressive summer heat. They were side effects of the hormonal changes happening in her body.

Menopause symptoms range from mild muscle pain and hot flashes to depression and blackouts, as in Suzuki’s extreme case, and usually occur between the ages of 45 and 55. They can continue for up to 10 years before a woman’s final menstrual period. 

In eastern Asia, home to some of the world’s fastest-aging societies — including Japan, South Korea, and Singapore — stories like Suzuki’s are becoming difficult to ignore. United Nations data shows that, as of 2021, 34% of women in East and Southeast Asia were over 50 – 8% more than the global average and a 19% increase from 30 years earlier. 

The economic impact of menopause in the region is already striking. 

A 2021 survey by Japanese broadcaster NHK revealed over 9% of women in their 40s and 50s – or 460,000 women nationwide – drop out of the workforce due to menopause-related symptoms every year.

The economic loss Japan incurs as a result of women underperforming, not showing up for work or quitting their jobs because of menopause amounts to 1.9 trillion yen ($12 billion) a year, according to data released last month by the Ministry of Economy, Trade and Industry.

“Menopause is a major challenge that businesses need to overcome,” said Zhou Yanfei, a professor of labor economics at Japan Women’s University. “Female employees working at reduced capacity can trigger significant losses.” 

Suzuki was one of those employees. In the weeks following her blackout at the intersection, her condition worsened, to the point where she could not get out of bed. “All I wanted was to rest, relax and be released [from my symptoms],” she said. Two months and multiple hospital visits later, Suzuki resigned from her job in real estate. “I couldn’t work at all,” she told Nikkei. “I had no choice but to leave.” 

Eighteen months on, Suzuki is undergoing hormonal therapy to manage her symptoms and recently started a new job at a local health center. In her spare time, she works as a lecturer, leading online seminars to raise awareness of menopause and how to treat it. “If I had known more about menopause back then … that there was hope I would recover, I don’t think I would have left my job,” she said.

Suzuki is part of a budding movement across aging Asia to better understand, treat and support menopausal women.

Ahead of International Women’s Day, Nikkei Asia is highlighting some of the doctors, activists and businesses at the forefront of this movement. 

Their insights reveal a pressing need for more data, care and investment surrounding menopause – a need the World Economic Forum refers to as the menopause “health gap.” For Asian women, that gap is exacerbated by their under-representation in mainstream clinical studies and a longstanding social taboo around female reproductive health. 

“There is such a stigma around menopause that most women don’t even want to talk about it -- it's seen as the end of womanhood,” said Hiromi Yoshikata, a doctor and director of Yoshikata Obstetric & Gynecologic Clinic in Yokohama, Japan. “Unless there is some kind of top-down approach … large-scale studies are challenging.” 

The incentives for governments and businesses to invest in menopause research are clear: Closing the menopause health gap is not only fundamental to keeping populations healthier for longer but also presents an enormous economic opportunity. Addressing the global lack of menopause-related data and treatments could add $120 billion to the world’s GDP, according to a January report by the WEF. 

Due to the historic under-representation of women in clinical trials, the lack of women in medicine and societies’ prioritization of fertility over other female health issues, menopause remains largely a medical mystery, doctors say. 

“What we know about reproductive aging, and the impact it has on a woman, is so limited,” said Zhongwei Huang, a consultant in the Department of Obstetrics & Gynaecology at Singapore's National University Hospital and deputy director of the Bia Echo Asia Centre for Reproductive Longevity and Equality (ACRLE). 

ACRLE, which opened in Singapore in 2021 with an $8 million gift from the Bia-Echo Foundation, founded by U.S.-based lawyer and entrepreneur Nicole Shanahan, is one of a small but growing number of organizations in Asia trying to decipher the female reproductive aging process. 

What scientists know so far is that women’s ovaries begin aging earlier, and at a much faster rate, than the rest of their bodies. This is different from male reproductive aging, which begins in the 40s and continues gradually until death, usually without serious symptoms, Huang explained. 

Huang’s team, a group of around 20 researchers from across the world, uses a mixture of lab-based research, human trials and population modeling to identify the biomarkers of reproductive aging by observing changes in blood and tissues.

One of ACRLE's main goals is determining the link between the ovaries and women’s overall health, which Huang believes is strong. “There’s enough good epidemiological data to show that women who are able to conceive later in life are able to live longer,” he said. 

Women who experience menopause prematurely, in their 30s and early 40s, are at increased risk of cardiovascular problems, osteoporosis and metabolic disease for the remainder of their lives, implying the biological impact of menopause continues far beyond a woman’s final period, Huang added.

Huang hopes his research will help doctors diagnose, treat and potentially delay menopause in the future. “Knowing that menopause is a part of aging but that we can do something about it and there are solutions out there … brings a lot more autonomy to women,” he said.

One problem holding research back is that “there’s so little data available on Asian populations,” Huang said. Women of Asian descent have long been excluded from major menopause studies, he added, partly due to a longstanding, now de-bunked, myth that Asian women do not suffer from menopausal symptoms.

“Asian [women] do have symptoms, but they present in different ways,” Huang said. “Asia is so unique.” 

Small-scale studies so far suggest women in Asia experience menopause symptoms at similar rates to their Western counterparts but are less likely to exhibit those typically reported by women in the U.S. and Europe, like hot flashes and nausea.

According to the North American Menopause Society, around 75% of women in the U.S. experience hot flashes during their menopausal years. In contrast, data released last year by Singapore’s National University Hospital revealed the most prevalent menopause symptom amongst Singaporean women of Chinese, Malay and Indian descent was joint and muscle pain, with hot flashes detected in only 19% of the 1,000 women surveyed. 

The highly personalized nature of menopause – symptoms and severity vary from woman to woman – makes large-scale data collection vital for developing new treatments, Huang added. 

But gathering such data is difficult in Asia, said Kim Mee-ran, a Seoul-based gynecologist and president of the Korean Society of Menopause. “It is hard to get funds for widescale research here," she told Nikkei, “because menopause is not considered an ‘urgent’ issue, compared to cancer or other diseases.” 

Government investment in women’s health, as seen in the U.S., is necessary for progress, Kim added.

In Japan, an important precedent was set in 2022, when the Ministry of Health, Labor and Welfare conducted the country’s first nationwide study on menopause, following NHK’s survey exposing the economic risks of the issue. 

The government’s poll, answered by 2,975 women aged 20-64, revealed 44% of those in their 50s had experienced menopause symptoms of some kind. Seventeen percent said those symptoms had impacted their ability to “contribute to society.”

The government’s ramped-up interest in menopause stems not only from Japan’s battle with a rapidly aging population but also its struggle to increase female participation in the labor force. Experts say menopause is keeping some women out of senior roles.

“In Japan, employees typically reach senior positions at a later age than in most other countries, including China, India and the U.S.,” Zhou, the labor economist, said.

During this critical period for career progression, many women experience debilitating hormonal symptoms, pushing them to avoid or reject promotions, Zhou said.

Addressing this “menopause barrier,” as Zhou puts it, has become a priority for the government. Last year, Prime Minister Fumio Kishida set a goal for Tokyo Stock Exchange Prime-listed companies to fill at least 30% of executive board roles with women by 2030. As of 2022, that figure was 11%. 

“Promoting awareness of and treatment for menopause is necessary to ensure women experiencing even severe symptoms do not face obstacles to continued employment and career advancement,” a representative for Japan’s Gender Equality Bureau Cabinet Office told Nikkei.

The next few years will be a moment of truth for Japan’s efforts to close its menopause gap, as the large cohort of women born around 1971-74 – Japan’s second baby boom – hit their menopausal years, Zhou said.

Even for women who remain at work throughout menopause, symptoms can have a serious impact on productivity.

In Japan, where the number of permanent female workers aged over 45 has increased by 40% in the past decade, “presenteeism” is a major concern, Zhou said. “Many women don’t want to upset the status quo [by telling their boss they are menopausal], so continue to show up for work even when feeling unwell.” 

To combat this, some companies have started offering “menopause leave.”

Nomura Real Estate Holdings introduced a system last April that allows women experiencing menopause – and other female health issues like pre-menstrual syndrome and infertility – to take paid time off once a month, on top of ordinary annual leave. Employees can use the time to rest or for doctors’ appointments and hospital visits.

“We implemented this system to improve productivity and retention among women in managerial positions,” a representative for Nomura told Nikkei. The company aims to increase female managers and managerial candidates to 20% by 2030, up from 14% last year.  

In March 2022, car component manufacturer Aisin introduced an in-house menopause consultation service as part of its push to attract more women to the male-dominated auto industry. Via the new system, female employees can meet with gynecologists online to discuss their symptoms and receive prescriptions for Chinese herbal remedies. 

Such initiatives are fueled by growing pressure from the government for businesses to make working environments more welcoming for women. “The cabinet office is carrying out mandatory women’s health training for all managers,” said a representative from the gender equality bureau. “We hope measures like this will be replicated in other ministries, and across the private sector.”

Raising awareness of menopause in the workplace is vital, Zhou said, because many women still feel too embarrassed to consult their male bosses about it, even at companies that offer menopause leave.

Chebura, a nonprofit organization founded in 2014 by former actress Kyoko Nagata, is on a mission to solve this. The group provides seminars on menopause for Japanese businesses, community centers and local governments. Their events target both female and male employees. 

“It’s so important for [men] to understand menopause, too,” Nagata, who started Chebura after witnessing her mother suffer from depression during her menopausal years, told Nikkei. “When we host female-only events, women often tell us: ‘I wish my boss participated in this.' Or, ‘I wish my male colleagues knew about this.’”

After recovering from her near accident, Suzuki joined Chebura as an instructor last year. “I want [managers] to create working environments where people can share their experiences with menopause freely,” she said. 

Activists in Singapore are hoping their government will follow Japan's lead.

The city-state, “known for its advanced healthcare system and progressive workplace policies … does not yet appear to have specific government-led initiatives aimed directly at supporting women going through menopause,” said Low Chai Ling, a Singaporean clinician and author of Get Your Sexy Back: Biohacking Your Menopause Journey.

For now, the healthcare industry is leading the charge to treat Singapore's growing population of menopausal women. Women aged 45-59 comprised 11% of the city's total population in 2023, up 4% from thirty years ago, government statistics show. 

Rukshini Puvanendran, doctor and co-director of the Menopause Center at KK Women’s and Children’s Hospital, says she has seen a threefold increase in women seeking help for perimenopausal and menopausal symptoms over the past 15 years. Perimenopause refers to the phase preceding menopause, when symptoms begin to appear. 

To address the increased demand for menopause care, KK in October established Singapore’s first dedicated menopause health center.

Located within the hospital’s Women’s Health and Wellness Centre, the hub provides hormone replacement therapy (HRT), a menopause treatment usually administered via tablets, skin patches or gel that replenishes female hormones in the body. The center also offers counseling and seminars to support women and promote public education on menopause. 

The business world has begun to take notice of East Asia’s burgeoning demand for menopause support, which presents an enormous, largely untapped, opportunity. According to the WEF’s January report on “Closing the Women's Health Gap,” the global market potential for menopause treatments is $350 billion, more than the world’s total annual expenditure on cardiovascular disease.

“The women’s health care market is a blue ocean. … There’s a lot of new potential,” said Amina Sugimoto, CEO and co-founder of fermata, a female health tech startup accelerator based in Tokyo.

The appetite for new menopause solutions is so strong because of a lack of choice in the current market, ACRLE’s Huang said. “Many women come to me asking if I can offer them anything other than HRT,” he said. 

Some women choose to avoid HRT because of concerns about its side effects. Studies from the U.S. in the early 2000s suggested HRT could heighten the risk of breast cancer, but doctors remain divided on the dangers of the treatment. While HRT has been proven to raise cancer risk, it poses “less risk than lifestyle issues, obesity and alcohol,” gynecologist Yoshikata said. “So there is no need to worry too much.”

Some scientists think East Asia could hold the key to a natural HRT alternative. “Something that is specific and unique within the region is traditional Chinese medicine,” Huang said. “Exciting” preclinical research from China shows that some herbal remedies have an impact on ovarian aging, he added.

In South Korea, Dongkook Pharmaceutical has been offering women herbal alternatives to HRT for over two decades. Dongkook released its flagship menopause drug, Feramin Q, in 2001. 

The tablet, marketed as an “all-natural hormone replacement medicine,” aims to relieve the physical and psychological symptoms of menopause using the herbs black cohosh and St. John’s wort. According to market analytics agency Iqvia, Feramin Q has been South Korea’s best-selling non-prescription menopause drug for the past 15 years.

Hoping to capitalize further on menopause, Dongkook conducts regular market research among middle-aged women. “Women need to manage menopausal symptoms early on, to prevent a wide range of diseases,” a marketing official at Dongkook said. “We will continue to raise awareness of this.”

But Seoul-based doctor Kim Mee-ran is skeptical about the pharmaceutical industry’s recent interest in menopause. “Pharma companies do not usually undertake much clinical research, due to high costs,” she said. Natural solutions “could be helpful,” she added, but “cannot be alternatives to HRT.”

A representative for Dongkook told Nikkei that Feramin Q has been clinically tested and proven to be “safe and effective.” 

Entrepreneurs in the region are exploring a third menopause treatment option, technology. According to market research agency FemTech Analytics, the world’s femtech market will be worth $75 billion by 2025, double its size in 2020. Femtech refers to technology that addresses health issues exclusive to biological women, such as pregnancy, menstruation and menopause.

Menopause care currently makes up around 7% of the total global femtech market. Particularly in Asia, the development of new technologies is hindered by a lack of funding from the male-dominated venture capital industry, fermata’s Sugimoto said.

According to Tokyo Women in VC, only 10% of venture capitalists in Japan are women. 

But investors are gradually waking up to the huge gains on offer in the menopause market.

Sherry Shi, a former consultant who hails from China and has a doctorate in mathematics, founded femtech startup YStory in January 2023 with her best friend, data scientist Janet Yu. The pair launched JoyHer, a menopause monitoring app, last July, after securing funding from Japanese VCs Anri and Deepcore. 

JoyHer, which has been downloaded over 15,000 times in Japan since its release, allows women to log their daily menopause symptoms and consult with a gynecologist from Kyoto University in real-time.

The app also offers a community chat function, utilized by 90% of users, where women can share their experiences and exchange advice. 

JoyHer data reveals each woman experiences an average of 14.5 different menopause symptoms.

Shi said menopause’s untapped market potential helped lure investors, fast-tracking the fundraising process. “The VCs believed in us because they think the market is very huge, and there are not many players yet,” she told Nikkei. 

JoyHer’s tech-forward approach to menopause care was also a pull, co-founder Yu said. The app uses artificial intelligence to analyze users’ symptoms and provide personalized daily health tips, such as what to eat, how to exercise and when to visit a doctor. “The data helps users to get in control of their symptoms … and take action,” Yu said, adding that the team hopes to expand into the Chinese and U.S. markets soon. 

Yu echoed the message conveyed loud and clear by experts across the region: When it comes to closing Asia’s menopause health gap, “data is the solution.” 

^{Editing: Alice French, Charles Clover
Photo editing: Ken Kobayashi, Yuki Kohara
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