Karnataka’s Menopause Policy Is a Step Forward, But Data Gaps Remain
Karnataka is right to notice menopause. It should also ask how women get there.
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Karnataka's health department has announced 'Ruthutaare', a menopause-focused programme poised to become India's first dedicated women's health policy. According to Health Minister UT Khader, it is the first such initiative in the country and possibly in Asia.
The programme includes a house-to-house survey by ASHA workers to identify women in perimenopause and menopause, awareness campaigns on nutrition, sleep, exercise and stress, family sensitisation, the establishment of a policy committee, appointment of a celebrity ambassador, and the eventual creation of mid-life clinics in every district.
Acknowledgement of menopause by any state government is a significant step towards women’s empowerment. Indian health policy in the past has focused on women, primarily in their reproductive years. However, there is limited attention paid to health concerns beyond childbirth. One reason could be the absence of menopause as a specific item in national programmes or the medical curriculum.
Karnataka’s new policy is a welcome move, as it represents a departure from the absence of a menopause policy and deserves to be celebrated.
However, the programme as currently designed is based on an assumption not supported by national data: that menopause in India is a natural transition occurring in the late forties and is best managed through lifestyle interventions.
For a significant proportion of Indian women, menopause occurs as a result of surgical intervention, often years earlier than expected.
What the Karnataka Survey Will Miss
Data from the National Family Health Survey (NFHS-5) showed that nationally, 14.7 per cent of currently married women aged 30–49 were already in menopause.
Among rural women aged 30–39, close to 5 per cent had reached menopause before 40, the clinical threshold for premature menopause. International estimates typically put that figure at around 1 per cent.
Karnataka's overall profile is better than the national average: about 12 per cent of women aged 30–49 are in menopause, compared with 14.7 per cent nationally. Which makes the younger end more striking, not less. Among Karnataka's women aged 30–34, 2.7 per cent were already menopausal, above the national figure of 2.4 per cent. By ages 40–41, roughly one in eleven Karnataka women had reached menopause; by 46–47, one in four.
The minister has identified approximately 4.2 million women aged 40 to 60 as the target group. Limiting the survey to this age range will exclude women who experienced menopause at younger ages, including those who stopped menstruating before 40.
Menopause as a Surgical Outcome
The distribution of premature menopause is where the policy question really lies. A recent study published in Scientific Reports showed that among women with no education, 6.85 per cent had reached menopause before 40. Among women with higher education, 0.94 per cent had. A seven-fold gap.
Biology doesn’t sort itself by schooling. Hence, the study decomposed the gap and found that almost three-quarters of this gap is explained by undergoing a hysterectomy, rather than by diet, stress, or workplace conditions.
This finding is counterintuitive, as it might be expected that poorer, less-educated women would have less access to surgical care. The most plausible explanation is that the health system frequently offers hysterectomy as the primary response to heavy or irregular bleeding, particularly to women who may lack information about alternative treatments and who cannot afford to lose income during extended conservative management.
The minister also indicated that the state will be commissioning the research to understand why Indian women are experiencing menopause earlier than women in other countries, focusing on factors such as diet, stress, and workplace conditions. However, analysis of NFHS microdata suggests that a large proportion of early menopause cases in India are attributable to medical intervention rather than these factors.
How to Design the Policy?
These findings do not suggest that Ruthutaare should be discontinued. Rather, they indicate the need to broaden the programme in three specific ways during the design phase.
First, expand the age range. Restricting the survey to women aged 40 and above will systematically exclude cases of surgical menopause, which often occur at younger ages. The ASHA checklist should include women in their thirties as well. This adjustment is cost-effective at the design stage and difficult to implement retrospectively.
Second, include a question on hysterectomy history. Incorporating questions about hysterectomy and age at surgery into the ASHA checklist would provide Karnataka with the first state-level administrative data on surgical menopause. This information would help identify women at the highest long-term risk, as premature menopause is associated with increased cardiovascular, bone, and cognitive risks over time. Targeted screening is only effective if the at-risk population is accurately identified.
Third, re-evaluating the emphasis on non-medication. A preventive, lifestyle-based approach is the best way to manage natural menopause. However, it might not be sufficient for women who have to undergo surgical menopause, and that too at a young age. These women may need hormone therapy, bone health monitoring, and a heart checkup. Additionally, a policy seeking to avoid medication should also address the high rates of surgical intervention leading to early menopause.
Addressing surgical intervention rates may extend beyond the immediate scope of a menopause awareness campaign. The policy committee is reportedly chaired by an infertility specialist. A menopause policy developed primarily from a reproductive medicine perspective may focus on menopause as the end of fertility, rather than as the onset of several decades of increased cardiovascular, skeletal, and cognitive risk. Including an endocrinologist, a public health physician, and an expert in health system incentives on the committee would further strengthen the policy's design.
Beyond the Point
Overall, the minister indicated that other states should also adopt a similar policy. However, if implemented, these states are likely to replicate Karnataka's approach. Hence, it is likely to include limitations of the current design, which signifies the importance of addressing such issues during the policy development phase rather than the implementation phase.
Since our earlier days, the Indian health system has seen the uterus primarily as a child-bearing organ, with limited attention to women's health beyond the reproductive years.
Karnataka is the first state to acknowledge that women's health extends beyond childbearing. To fully realise this commitment, it is necessary to examine the factors contributing to early menopause and the decision-making processes involved.
The findings cited are from Babbar, Singh and Sivakami (2024), "Rising premature menopause and variations by education level in India.
(The author is Assistant Professor of Economics at XLRI Jamshedpur. This is an opinion piece and the views expressed are personal. The Quint does not endorse or is responsible for them.)