Breaking the silence and building strength; rethinking menopause care through exercise and cultural insight

Menopause is a significant life stage for women worldwide, although its management is often overlooked in health agendas beyond reproductive age ( 1 ). By the late 2020s, an estimated 76% of postmenopausal women globally will live in developing regions across Asia, Africa, and the Middle East ( 2 ). It is widely recognised as a physiological transition associated with symptom variability, where some individuals experience minimal disruption while others experience severe and acute manifestations (e.g. vasomotor symptoms), alongside longer-term changes in cardiometabolic, musculoskeletal, and neurocognitive risk profiles ( 3 ). These experiences are heterogeneous and non-universal ( 4 ). Menopause is characterised by symptom patterns and health risks that unfold across distinct temporal trajectories, underscoring the need for stage-specific understanding and intervention. Acute symptoms typically emerge during the perimenopausal transition and early postmenopause and include vasomotor disturbances, sleep disruption, mood lability, and somatic discomfort, which may fluctuate in intensity but can substantially impair daily functioning ( 5 ). Persistent symptoms, such as genitourinary syndrome of menopause, chronic pain, fatigue, and ongoing psychological distress, often continue well beyond the menopausal transition and may require sustained management strategies. In contrast, longer-term risk trajectories develop more gradually and include increased risks of cardiovascular disease, metabolic dysfunction, osteoporosis, sarcopenia, and cognitive decline, reflecting cumulative hormonal, metabolic, and lifestyle influences ( 6 ). Distinguishing between these temporal domains is essential for aligning prevention, symptom management, and long-term health promotion strategies throughout midlife and beyond. Additionally, access to appropriate care remains highly uneven, especially in low- and middle-income countries (LMICs), where healthcare professionals with specialised expertise in menopause are often lacking, making menopause a pressing global public health issue ( 7 , 8 ). A visual of the framework MARIE exercise framework that is proposed to be used to develop interventions for people experiencing perimenopausal, menopausal, and postmenopausal. Despite being the most effective intervention for menopause-related conditions, hormone replacement therapy remains underutilised in LMICs due to barriers such as high costs and limited access ( 9 , 10 ). Exercise has emerged as a promising, cost-effective strategy to reduce the severity of menopausal symptoms and improve quality of life ( 1 ). Beyond physical benefits, regular exercise can positively impact brain health by modulating mood and neurochemistry. This article critically examines the role of exercise in managing menopausal symptoms for women in Asia, Africa, and the Middle East, drawing on evidence from research and reports. It also explores how cultural and religious beliefs influence women's access to exercise, assesses current policy landscapes and healthcare system gaps, and highlights case examples. Finally, we propose pragmatic, sustainable approaches for integrating exercise into menopause care in culturally appropriate ways, encompassing natural, surgical, and medical menopause from perimenopause to postmenopause. Physical activity refers to any bodily movement produced by skeletal muscles that results in energy expenditure and includes incidental activities (such as household tasks or active transport), occupational activity (work-related physical demands), and lifestyle movement (walking, gardening, or caregiving) ( 11 ). In contrast, exercise is a subset of physical activity that is structured, planned, intentional, and repetitive, undertaken with the specific objective of improving or maintaining physical fitness, health, or functional capacity ( 12 ). Both physical activity and exercise can be strategically leveraged to support menopausal health, but their feasibility and acceptability vary across health systems and cultural contexts ( 13 ). In resource-limited or time-constrained settings, integrating incidental and lifestyle physical activity into daily routines may offer a more accessible and culturally congruent approach, whereas structured exercise programmes may be more feasible within formal healthcare systems or organised community settings. Recognising and valuing both forms enables the development of equitable, context-sensitive strategies to promote physical and mental well-being during the menopausal transition. Exercise should be conceptualised as a multisystem, non-pharmacological intervention with broad relevance across the menopausal transition. Regular participation in appropriately prescribed exercise has been shown to alleviate vasomotor and somatic symptoms, including hot flushes, sleep disturbance, fatigue, and musculoskeletal discomfort, through improvements in thermoregulatory stability, autonomic balance, and inflammatory modulation. Beyond somatic effects, exercise confers substantial benefits for neurocognitive and psychological health, supporting mood regulation, stress resilience, sleep quality, and cognitive function via neuroendocrine, vascular, and neuroplastic mechanisms. Additionally, exercise plays a critical role in preserving cardiometabolic and musculoskeletal health, mitigating menopause-associated increases in cardiovascular risk, insulin resistance, central adiposity, sarcopenia, and bone loss. By acting simultaneously on hormonal, neural, metabolic, and structural pathways, exercise offers a holistic, scalable, and adaptable strategy for improving health-related quality of life in menopausal individuals across diverse clinical and cultural contexts. Regular physical activity is a well-established non-pharmacological intervention that confers wide-ranging benefits for midlife and older women. Delanerolle et al.’s ( 14 ) meta-analysis indicated cardiometabolic disorders could be reduced by the use of hormonal-replacement therapies (HRTs), although the data for the primary studies were primarily from high-income countries (HICs). Similarly, the risks of exacerbation of menopausal symptoms need to be considered within this context. One such issue could be pelvic organ prolapse, or persistent stress incontinence and urinary tract infections, as indicated by Mudalige et al. ( 15 ) who showed the lack of menopause even being considered as part of the studies that they conducted a meta-analysis on. For menopausal women, exercise can alleviate many symptoms and health risks ( Table 1 ) by releasing a host of mood-boosting neurochemicals. When women exercise, the body increases production of endorphins, serotonin, and dopamine neurotransmitters that promote euphoria and combat stress and depression. This makes exercise a valuable adjunct to menopause care for maintaining not just physical fitness but also “neuro-fitness” ( 1 , 16 ). Building strength through movement: evidence-based exercise benefits across menopausal symptom domains. In Asia, diverse cultural and religious contexts shape women's experiences of menopause and their attitudes towards exercise. Many Asian societies traditionally view menopause as a natural life transition rather than a medical condition, which can be a double-edged sword. On the one hand, there may be less overt pathologising of menopausal symptoms; on the other, women may feel expected to endure symptoms quietly without seeking help. In many LMIC contexts, attitudes towards menopause and attitudes towards exercise are deeply interconnected, particularly for midlife women. Cultural norms that position menopause as a private experience to be endured silently often coexist with restrictions on women's bodily autonomy, gendered expectations surrounding aging and physical visibility, and social norms that limit women's participation in public or structured physical activity. These intersecting cultural and social constraints directly shape the acceptability, feasibility, and uptake of exercise during midlife. Treating attitudes towards menopause and exercise as independent constructs reflects a Global North conceptual separation that does not adequately capture the lived realities of women in many LMIC settings, where health behaviours are embedded within broader gendered, cultural, and structural contexts. Cultural norms and gender roles in parts of Asia have historically deprioritised leisure exercise for midlife women ( 23 ). For example, Confucian-influenced cultures emphasise women's duties to family and valorise intellectual pursuits over physical activity. In a study of Asian American midlife women reflecting on their heritage, the participants felt that “physical activity was perceived to be not for Asian girls ” because traditional values didn’t place importance on women exercising ( 24 ). Women often put household responsibilities and care of children first, leaving little time for themselves. Additionally, strong notions of modesty and propriety can limit the appropriate activities for women. In South Asian communities, many women are nervous about participating in exercise because certain activities conflict with social expectations of modesty and femininity. High-impact or gym-based exercises, for instance, may be seen as unseemly or too exposing. As a result, Asian women may opt for walking or home-based routines over public sports. One qualitative insight noted that South Asian midlife women would benefit from more culturally tailored support, providing women-only exercise spaces, guidance on suitable exercise forms (e.g. yoga and dance), and community awareness to normalise women's fitness ( 25 ). Despite these barriers, traditional Asian practices and perspectives can also facilitate exercise. Yoga, tai chi, qigong, and other mind–body exercises have their origins in Asia and are widely respected ( 26 ). These gentle forms of activity are often culturally acceptable for older women and have proven benefits for menopause management. For instance, yoga and tai chi classes for middle-aged women have gained popularity in countries such as India and China, blending exercise with cultural wellness philosophies. Some Asian cultures frame menopause in a more positive light, such as the Japanese term konenki which implies a period of renewal and regeneration. In Japan, where diet and lifelong physical activity are emphasised, women historically reported fewer hot flashes and attributed their smoother midlife transition to a healthy lifestyle. Researchers have credited Japanese women's relatively late menopause to a combination of diet, regular exercise, universal education, and preventive healthcare traditions. This suggests that integrating exercise into daily life, common in some East Asian contexts, can yield tangible benefits ( 16 ). Across much of Asia, menopause care has not received the policy attention it deserves ( 27 ). Health systems in low- and middle-income Asian countries traditionally focus on maternal and child health, with limited resources dedicated to older women's health. As an example, India's national health programmes have long centred on family planning and safe childbirth, resulting in menopausal health being sidelined. There is a pronounced data and research gap on menopausal women in Asia, which hampers evidence-based policy development. Consequently, few countries have comprehensive guidelines or public initiatives addressing menopause or promoting exercise for midlife women. Where clinical guidelines exist (e.g. the Indian Menopause Society's recommendation), implementation remains limited ( 28 ). Social stigma also plays a role: many Asian women hesitate to discuss menopause openly, so they may not seek out exercise programmes even if available ( 29 ). The lack of targeted interventions means women often rely on self-care. Notably, Asian women aware of exercise benefits treat it as self-care; a study in Saudi Arabia (West Asia) found that participants viewed exercise as a “valuable self-care practice” during menopause and sought out home exercise videos for guidance. This points to an unmet need for supportive infrastructure. Overall, the Asian context calls for greater policy recognition of menopause as a health priority and culturally sensitive programmes that encourage exercise among midlife women. African women experience menopause against a backdrop of varied cultural beliefs—ranging from reverence for older women's wisdom to stigma and misconceptions. In many parts of Africa, menopause has traditionally been a private matter, not openly discussed, which affects how women cope and whether they engage in health-seeking behaviours such as exercise ( 30 ). As activist Sue Mbaya noted, “negative cultural beliefs about menopause” in some African communities fuel stigma, with menopausal women unfairly deemed “unattractive” or “incapable”. This stigma can isolate women and discourage them from participating in public activities, including exercise groups. Indeed, qualitative studies in countries like Zimbabwe and South Africa revealed that many women had received little information about menopause and felt they simply had to “endure” the physical and psychological symptoms in silence ( 31 ). Such attitudes reflect a gap in education and support. However, Africa is culturally diverse, and positive perspectives upon which to build. In numerous African societies, postmenopausal women attain greater social freedom and authority , no longer bound by certain reproductive-related restrictions. For example, a woman beyond childbearing age may enjoy more respect in some Islamic African communities and parts of sub-Saharan Africa. She can take on leadership roles within the family or community ( 32 ). Anthropological accounts from West Africa describe “menopausal matriarchs” who become key decision-makers and custodians of knowledge in their communities. This elevated status could be leveraged to engage older women in community wellness initiatives, as they may influence and mentor younger women. Physical activity patterns in Africa are also shaped by lifestyle and beauty ideals. In rural areas, women's daily lives often involve substantial physical labour (farming, fetching water, etc.), which can maintain fitness but is not usually framed as exercise. In urban settings, more sedentary lifestyles prevail, yet formal exercise is not widespread, especially among older women. Social determinants play a role: one study noted that in Ghana, cultural perceptions of body image influence postmenopausal women's activity levels. If a fuller figure is associated with status or health, women might be less motivated to exercise for weight control, highlighting the need to tailor messages about fitness in culturally relevant terms. Moreover, common barriers such as time constraints and a lack of facilities are pronounced for African women. Women often prioritise family needs and may have limited leisure time or safe spaces to exercise ( 33 ). Menopause has only recently started to gain visibility on the policy radar in Africa. Most African health systems face competing urgent issues (infectious diseases, maternal mortality, etc.), and menopause care has been largely neglected. As a result, there is minimal government programming for menopause; few clinics specialise in midlife women's health, and healthcare providers may receive little training on managing menopause beyond offering menopausal hormone therapy if available. This lack of structured support means that interventions such as exercise are not systematically promoted. The situation is beginning to change: grassroots movements and NGOs are spearheading a “menopause revolution” in parts of Africa. They emphasise awareness, destigmatisation, and lifestyle management. In countries such as South Africa and Uganda, new menopause societies and support networks are forming. However, large gaps remain—especially in rural areas where information is scarce and in health policies that rarely mention menopause. The need for context-specific research is acute; as Mbaya observes, sub-Saharan Africa suffers from “low levels of development, competing needs and lower investment in research” on menopause ( 34 ). Addressing these gaps will require including menopause in national health strategies and recognising that simple lifestyle interventions such as exercise can have outsized benefits for this population of women who are living longer than ever before. In the Middle East (including North Africa and West Asia), women's access to exercise during menopause is influenced by conservative social norms and religious practices. Many countries in this region have strong traditions around gender roles and modesty, which can create specific challenges for women's physical activity. For example, gender segregation and dress codes in conservative societies mean women often need women-only spaces or appropriate attire to exercise comfortably. A systematic overview of 17 Middle East and North Africa ( 35 ) countries identified gender and cultural norms as among the most commonly reported barriers to physical activity for women ( 36 ). Simply put, being female and of advanced age in these societies is associated with less exercise, in part because older women are expected to remain home or are not encouraged to engage in sport. Practical hurdles such as a lack of female gyms, limited time due to family duties, and even harsh climate (extreme heat) further compound the issue. Cultural and religious beliefs can both hinder and help menopausal women seeking exercise. On one side, menopause remains a sensitive or even taboo topic in parts of the Middle East. In Saudi Arabia, for instance, many women silently endure menopausal changes due to cultural taboos and fear of stigma. This silence can prevent them from seeking group support or asking doctors about non-pharmacological strategies such as exercise. Interviews with Saudi women revealed concerns about being seen as “old” or less attractive, leading them to keep symptoms private. On the other side, Islamic teachings provide an opportunity: after menopause, women are relieved from certain religious restrictions (such as fasting during menstruation or observing strict purdah in some interpretations), potentially giving them more freedom to engage in activities outside the home. Many Middle Eastern women view menopause positively as it grants a “relief from menstruation and a newfound freedom to engage in religious activities at any time” ( 37 ). This positive outlook can be harnessed to encourage postmenopausal women to invest in their health. Indeed, some women in the region are proactively adopting exercise as self-care. The Saudi qualitative study noted that participants embraced holistic health practices—maintaining a balanced diet, regular exercise, meditation, and good sleep—to cope with menopause, often preferring these to medical treatments. Much like Asia and Africa, the Middle East has only nascent recognition of menopause in health policy. Few Middle Eastern countries have national guidelines or public education campaigns on menopause ( 38 ). Women in conservative Arab states may have limited access to specialised care; for example, discussion of menopausal hormone therapy or menopause management might be minimal during routine clinic visits. Healthcare providers may not be fully trained to address menopause beyond treating it as a natural stage. In the Saudi study, women reported that doctors seldom brought up menopause management proactively—one noted that her gynaecologist “did not discuss anything about hot flashes or hormonal treatments”, focusing only on issues like screening and pelvic floor exercises ( 39 ). This indicates a gap in provider engagement and patient counselling. On a policy level, some countries are beginning to include women's health across the life course in their strategic plans, but implementation is slow. The lack of public conversation is a key issue; normalising menopause in the Middle East will require breaking the taboo so that women feel comfortable joining exercise classes or advocacy groups. Encouragingly, there are early signs of change—for instance, menopause was brought to the floor of Ghana's parliament by a politician and is being included in feminist agendas in Africa, and similar advocacy could spread to Middle Eastern contexts through women's health NGOs or influential figures. Despite challenges, innovative programmes in all three regions demonstrate how exercise can be woven into menopause support with culturally sensitive approaches ( Table 2 ) using examples offering learning points. They show that culturally aligned approaches, whether leveraging community solidarity in Africa, workplace infrastructure in Asia, or digital connectivity in the Middle East, can successfully integrate exercise into menopause care. Examples for community initiatives and emerging programmes. Table 3 indicates gaps where not all women are reached (rural women, those outside formal employment, etc.), and programme sustainability can be an issue if reliant on volunteerism or short-term funding. Nonetheless, these cases demonstrate that the barriers to menopausal women exercising can be overcome with creativity and culturally conscious planning. Summary of exercise-related strategies for menopause support. To improve menopause management for women in Asia, Africa, and the Middle East, it is crucial to adopt pragmatic, cost-effective, and sustainable approaches that embed exercise into care in culturally appropriate ways. Below are key strategies, informed by the evidence and contexts discussed: Exercise interventions for menopausal women should be community-based, culturally sensitive, and inclusive of all menopause types, including surgical and medically induced cases. Safe, women-only spaces and culturally adapted activities such as African dance, yoga, or courtyard walking can increase participation, especially in conservative settings. Integration into primary healthcare allows clinicians to prescribe and promote physical activity, supported by toolkits and culturally relevant resources. Technology and media, from SMS reminders to online video content, expand reach and sustain engagement, particularly for women in remote or resource-limited areas. Policy and advocacy efforts must formalise exercise promotion in national health strategies, ensuring structural support, workplace accommodations, and recognition of menopause as a public health and human rights priority ( Figure 1 ).

Exercise is a powerful implement in the menopausal toolkit—improving physical symptoms, bolstering brain health, and empowering women to take charge of their well-being. For women in Asia, Africa, and the Middle East, maximising this tool requires understanding and respecting cultural contexts. The evidence base shows that regular physical activity can alleviate depression, anxiety, insomnia, fatigue, and protect long-term cognitive health​. The sociological lens reminds us that a one-size approach will not fit all; programmes must negotiate gender norms, modesty, and differing attitudes towards menopause. Current efforts may offer blueprints for progress, although more culturally sensitive research on building effective exercise programmes is needed, which can help fill policy voids and healthcare gaps. By implementing community-grounded and culturally sensitive strategies, stakeholders, healthcare professionals, researchers, and policymakers can help women in these regions navigate menopause with greater ease and dignity. Integrating exercise into menopause care is not just about mitigating symptoms; it is about affirming women's agency and quality of life in the post-reproductive years. In every village, city, and society, a woman's midlife can be made healthier and happier by the simple act of moving her body, and it is time for our health systems to move with women.