Physical and mental health impact of perimenopause, menopause and post menopause in a diverse global population (MARIE Project- Global Chapter WP 2a): cross-sectional quantitative data from a mixed-methods study

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Background: Menopause is a major global health issue affecting cisgender women, transgender people, and gender-diverse populations, yet it remains under-recognised in research and policy, particularly in low-income and middle-income countries. Rising life expectancy means that an increasing proportion of the world's population spends many years in peri-, menopausal or post-menopausal stages, often with significant physical and psychological symptoms. Despite this burden, evidence from diverse global settings is limited. Methods: The MARIE WP2a project is a mixed-methods study that aimed to explore menopausal health across 13 countries. Study conducted from January 2024 to September 2025. Eligible participants (cis and transgender women) experiencing perimenopause, menopause, or post-menopause were recruited digitally from clinical and community settings from UK, Rwanda, Nigeria, Ghana, Tanzania, Sri Lanka, India, Pakistan, Nepal, Malaysia, Singapore, Oman and Brazil. Here, we report the quantitative component of the broader mixed-methods study within MARIE WP2a. The present analysis focuses exclusively on cross-sectional quantitative data to characterise symptom burden and associated health domains across participating countries. The primary aim of MARIE WP2a was to explore and document the physical and mental health impacts of perimenopause, menopause, and post-menopause among women. Secondary aims included exploratory assessment of symptom patterns in a subset of participants with repeated observations in the change in symptoms, lower-back pain, and quality of life. Symptom burden was assessed using validated scales covering psychological, somatic, pain, sleep, disability, and quality-of-life domains. Analyses included multivariable linear models; analyses involving repeated observations were conducted as sensitivity analyses only and, country-grouped heterogeneity models, and Gaussian Graphical Modelling to examine symptom interconnections. Findings: A total of 5228 participants from 13 countries were included. The median age was 55 years (IQR 50-61). The distribution of menopausal stages was 18.6% (n = 972) perimenopause, 32.2% (n = 1684) menopause, and 49.2% (n = 2572) post-menopause. Symptom burden varied substantially across countries and menopausal stages. The UK and Rwanda exhibited the highest levels of anxiety, depression, somatic burden, vasomotor symptoms, and overall MRS scores, while Nepal, Sri Lanka, Malaysia, and Singapore consistently showed lower burden. Clinical complexity including endometriosis, disability, long-term conditions, premature ovarian insufficiency, and GnRH analogue use was strongly associated with worse outcomes. Burnout emerged as the most central symptom connecting psychological and somatic domains. Interpretation: Menopause is a complex biopsychosocial transition shaped by geography, social determinants, and multimorbidity. Rather than testing causal hypotheses, this analysis is descriptive and hypothesis-generating, aiming to characterise patterns across diverse populations. Our findings highlight the need for holistic, multidisciplinary, equity-focused menopause care and policy approaches beyond narrowly symptom-based models. Future research should prioritise longitudinal designs and culturally grounded approaches to better understand trajectories and inform integrated models of care. Funding: NIHR Research Capability Fund.

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