Sage Journals: Discover world-class research

Abstract

Objective:

This study explored the health priorities and challenges of midlife women (ages 45–70) in British Columbia, Canada, to identify key elements for a comprehensive, dedicated midlife care program.

Design:

We conducted a cross-sectional, mixed methods online survey using convenience, non-probability sampling.

Methods:

An online survey (N = 980) assessed health priorities and concerns, care sources, and preferences for a dedicated midlife health program.

Results:

Staying physically fit was the top priority, followed by weight management, brain health, and mental wellness, with variations noted: Younger women prioritized weight and mental health, while older participants focused on brain and bone health. Respondents relied on family physicians or walk-in clinics for care, but reported unmet needs across services, including access barriers, care quality, and information gaps. Key components for a midlife program identified in this study were as follows: (1) integrated, whole-person care support; (2) preventative care and early detection; (3) mental health as a priority; (4) access that fits women’s lives; (5) relational, personalized, and competent care; (6) accessible information and navigation; and (7) community and peer connection.

Conclusions:

The findings offer insights for developing a midlife women’s health program that responds to varied and evolving health priorities through holistic, accessible, and patient-centered approaches.

Keywords

midlife women health priorities aging well integrated care menopause

Introduction

Midlife is a pivotal period in the life course, where increasing knowledge and responsibilities are balanced against progressive aging and functional decline.¹ During this time, many balance parenting, paid work, caregiving for aging parents, and household management. Midlife women’s health is an emerging area of care that addresses women’s unique health care needs for women aged 45–70, a range commonly used in large cohort studies of midlife experiences (e.g. the Australian Women’s Midlife Years (AMY) Study), and intended to capture both the menopausal transition and the postmenopausal years.^2,3

In Canada, the estimated age of natural menopause is around 51 years.⁴ Addressing women’s needs in midlife requires recognizing the role of menopause and ensuring access to specialized services for the management of difficult symptoms. While vasomotor symptoms and adverse mood often improve in the postmenopausal period, sleep complaints, vaginal dryness, and cognitive complaints (i.e., forgetfulness and difficulty concentrating) tend to persist or worsen with aging.⁵ Larger longitudinal cohort studies, such as the Study of Women’s Health Across the Nation (SWAN) in the United States have established that midlife is characterized by metabolic shifts, and major role transitions that affect well-being.⁶ Recently, the Health and Economics Research on Midlife Women in British Columbia study (HER-BC) found that majority of participants reported at least one moderate-to-severe menopause symptom, with vasomotor, sleep, mood, and cognitive complaints among the most common.⁷ Importantly, women reported that these symptoms interfered with work, caregiving, daily functioning, and quality of life, highlighting the broad social and economic impact, from missed workdays and reduced hours, to early retirement or leaving the workforce.

Addressing these challenges requires attention both to immediate symptom management and to broader approaches that influence health across the life course. Lifestyle behaviors and early disease intervention are well-established as having long-term impacts on aging. For example, physical activity has been shown to slow down functional decline in women,⁸ improved nutrition at midlife is associated with healthier aging outcomes,⁹ and lifestyle modifications and exercise interventions in postmenopausal women have improved bone health metrics.^10,11 Interventions targeting mood have also been demonstrated in reducing depressive symptoms in midlife women.¹² Moreover, longer term observational data support the sustained skeletal and mortality benefits of hormone therapy.¹³

An important consideration in designing a comprehensive care program for midlife women is that women not only seek to manage symptoms but also to “age well,” a concept that encompass maintaining physical health, cognitive function, psychological well-being, social engagement, and sense of purpose as they grow older.^14,15 Studies on older women’s health concerns have concluded that programs must address both the physiological and psychosocial needs women face to promote successful aging.^16,17 Recognition of the anxieties associated with aging and provision of overall health education were also identified as important priorities. Thus, offering adequate information on preventative health measures is essential for successful program implementation, alongside public health campaigns to raise menopause awareness, provider education, and investments in long-term multidisciplinary solutions.^7,17

In British Columbia (BC), more than one-third of women are aged 45–70,¹⁸ yet until recently, no comprehensive program existed in the province to address the unique health challenges faced by this population. BC Women’s Hospital + Health Centre (BCW), long recognized as a leader in women’s health care, advocacy, and research, has historically focused on maternal and newborn health, but is now expanding its mandate to midlife. The launch of the Complex Menopause Clinic, informed in part by consultative and research work, including our present study, marks an important step in advancing midlife women’s health care.

Our study builds on the results of previous literature by examining broader midlife health priorities beyond menopause by translating them into implications for a locally relevant midlife program. The goal of this study was to explore key areas relevant to women in midlife (ages 45–70) in BC through a community survey, focusing on their primary concerns, sources of care, and perspectives on what an ideal health program should encompass. This age range captures both the menopausal transition and postmenopausal years, periods characterized by intersecting health, social, and caregiving demands. This range also provided an opportunity to investigate health priorities beyond menopause by considering the lived realities of women navigating early aging.^19–21

To guide this work, we asked three exploratory research questions:

What stage-of-life concerns and health/wellness priorities do midlife women in BC report?

Which supports and health services midlife women use, and what are their unmet needs?

What features do women want in a dedicated midlife women’s health program?

While the first two questions establish women’s priorities and identify service gaps in the BC context, the third was the central focus of this study, aimed at guiding the design of a dedicated midlife health program in BC. Since the Complex Menopause Clinic has now been established, our findings remain critical for understanding broader midlife priorities and program needs in BC. In this article, we report on the survey results and describe how they provide context for this new program and its potential evolution toward more comprehensive models of care.

Methods

This study used a cross-sectional, mixed methods survey design with convenience, non-probability sampling, which captured self-reported priorities at a single time point. Analyses were descriptive and exploratory.

Questionnaire

The online questionnaire was informed by a review of existing literature and developed by a hospital-based design group that included hospital leaders, midlife women, clinicians with expertise in midlife care, and experts in evaluation and survey design.^1,21–24 This process ensured that the questionnaire addressed relevant issues and reflected the needs of the target population. For example, life-stage concern and health/wellness categories as answer choices were informed directly from synthesis of literature on midlife women and menopause and iteratively refined with input from the design group to establish content validity. The survey consisted of a combination of closed-ended questions, which assessed demographics, stage-of-life concerns, health and wellness priorities, service use and satisfaction with care, with open-text questions that invited participants to elaborate on unmet needs and suggest elements for a dedicated midlife women’s program. The full questionnaire is provided in the Supplementary Materials.

Participants

Our target population (inclusion criteria) comprised individuals aged 45–70 living in BC who identified as women. Individuals who did not meet these inclusion criteria were screened out and were not permitted to continue with the survey. Given our recruitment approach, the accessible population consisted of English-speaking BC residents in this age group who identified as women and were able to complete the online survey. Recruitment materials did not specify cisgender, transgender, or non-binary identities as eligibility criteria, and the survey did not include a gender identity question. Consequently, participants’ gender identities were not explicitly documented. While it is possible that the majority of respondents were cisgender women, due to the absence of explicitly inclusive language in the recruitment material, this cannot be confirmed. Throughout this article, the term “women” is used to refer to all individuals who identified as such when participating in the survey.

Recruitment and data collection

Participants were recruited through self-identification, with eligibility criteria outlined in the recruitment materials. The survey was accessible online and promoted through websites and social media of BCW and Emily Carr University of Art and Design, with the potential to reach women across the province. At the same time, other recruitment efforts were concentrated in Vancouver and the Lower Mainland, where study posters were displayed on bulletin boards at BCW, community centers, street corners, and in the offices of health care providers interested in midlife health. Data were collected from March to April 2019 using SurveyMonkey Canada. This study was approved by the University of British Columbia Children’s and Women’s Research Ethics Board (REB) (H19-00180), and the Emily Carr University’s REB. Because the survey was anonymous and conducted online, consent was implied through completion and submission, as approved by the REB and consistent with Canada’s Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2).

Statistical analysis

Prior to analysis, 20 blank surveys were excluded, leaving 980 surveys for analysis. The remaining surveys had fewer than 20% missing data, which was considered to have a negligible impact on the analysis, and therefore, all the surveys were retained.²⁵ During data cleaning, “other” responses to close-ended questions were either integrated into existing answer choices or assigned new codes for accurate categorization.

The final sample included N = 980 participants across three age groups (45–55: n = 504; 56–65: n = 387; 66–70: n = 89). Although no a priori sample size calculation was performed, the achieved sample was evaluated for adequacy relative to our descriptive aims. For single-group proportions (worst case p = 0.50), two-sided 95% margins of error (MOE) were ±4.37%, ±4.98%, and ±10.39% for the three groups (overall ±3.13%). For pairwise age-group comparisons of proportions (α = 0.05, two-sided; 80% power; p ≈ 0.50), the minimum detectable differences (MDD) were approximately 9.5 percentage points (504 versus 387), 16.1 points (504 versus 89), and 16.5 points (387 versus 89). These thresholds were considered sufficient to identify relevant group differences.

Descriptive statistics were conducted using SPSS 29.0 to summarize the demographics and survey responses. Cross-tabulations by age group examined associations between priorities, main health/wellness concerns, and satisfaction with services. Due to small cell sizes and 80.7% identifying as European, cross-tabulations by ethnicity were not performed. Chi-squared tests were used to assess the statistical significance of associations examined, and one-way ANOVA was conducted to assess differences between age groups concerning service utilization. Post hoc comparisons, with a Bonferroni correction applied, were performed when significant associations were found. The significance level was set at p < 0.05, unless adjusted for multiple comparison (Bonferroni correction applied).

In addition to the quantitative analysis, the open-text responses were thematically analyzed using an inductive approach.²⁶ After an initial read-through of all responses, a preliminary coding scheme was developed and refined as themes emerged. One author coded the data, and 20% was recoded by a second author, achieving an interrater reliability (Cohen’s kappa = 0.91) indicating an “almost perfect” agreement.²⁷ The second coder also reviewed all comments and confirmed that the codes reflected the data. Given the large number of responses, themes consistently re-emerged across participants, suggesting thematic saturation. The frequencies of the resulting codes were subsequently quantified using SPSS. Finally, the authors merged similar codes to identify overarching themes reflecting participant’s key perspectives.

Results

Profile of participants

Overall, 980 individuals completed the questionnaire, with participant demographics detailed in Table 1. About one-half of the participants (51.4%) were aged 45–55, 39.5% were 56–65, and 9.1% were 66–70. Most participants resided in the province’s Lower Mainland (85.0%) and identified as European (80.7%), with 8.2% identifying as Asian.

Table 1.

Demographic profile of participants (N = 980).

Participant demographics	n (%)
Age
45–55	504 (51.4%)
56–65	387 (39.5%)
66–70	89 (9.1%)
Place of residence
Vancouver Island and BC Islands	89 (9.1%)
Vancouver Lower Mainland	833 (85.0%)
Thompson Okanagan	36 (3.7%)
Kootenay Rockies	8 (0.8%)
Northern BC and Haida Gwaii	12 (1.2%)
Not reported or other^*	2 (0.2%)
Ethnicity/race
Indigenous (First Nations, Métis, Inuit)	18 (1.8%)
European (Western/Eastern)	791 (80.7%)
Asian (East, South, Southeast)	80 (8.2%)
Latin American	6 (0.6%)
Canadian (ethnicity not stated)	6 (0.6%)
Mixed heritage	53 (5.4%)
Other^*	12 (1.2%)
Don’t know	4 (0.4%)
Prefer not to answer or not reported	10 (1.0%)

“Other” category includes groups with fewer than five respondents.

Stage-of-life concerns and health/wellness priorities

Stage-of-life concerns

Table 2 displays the primary concerns reported by women across midlife age groups. The most common concerns across all age groups were staying physically fit (83.8%), followed by weight management (68.7%). Additional concerns included sleep (53.9%), career/retirement concerns (48.5%), family/relationship matters, including caring for aging parents (39.8%), financial concerns (35.8%), and menopause (33.0%).

Table 2.

Main concerns by stage of life (midlife).

Main concern	n (%)				p *
Main concern	Total (N = 980)	45–55 years (n = 504)	56–65 years (n = 387)	66–70 years (n = 89)	p *
Staying physically fit	821 (83.8%)	415 (82.3%)	327 (84.5%)	79 (88.8%)	0.28
Weight management	673 (68.7%)	355 (70.4%)	265 (68.5%)	53 (59.6%)	0.12
Sleep	528 (53.9%)	277 (55.0%)	206 (53.2%)	45 (50.6%)	0.71
Career/retirement/work-life balance	475 (48.5%)	259 (51.4%)	194 (50.1%)	22 (24.7%)	<0.001
Family/relationship/caring for aging parents	390 (39.8%)	224 (44.4%)	135 (34.9%)	30 (33.7%)	0.007
Financial concerns	351 (35.8%)	192 (38.1%)	128 (33.1%)	31 (34.8%)	0.29
Menopause	323 (33.0%)	264 (52.4%)	60 (15.5%)	0	<0.001
Memory	293 (29.9%)	115 (22.8%)	148 (38.2%)	30 (33.7%)	<0.001
Sexual health	232 (23.7%)	138 (27.4%)	76 (19.6%)	18 (20.2%)	0.02
Loss of loved ones	215 (21.9%)	106 (21.0%)	88 (22.7%)	21 (23.6%)	0.77
Housing	139 (14.2%)	73 (14.5%)	56 (14.5%)	10 (11.2%)	0.71
Death	88 (9.0%)	40 (7.9%)	37 (9.6%)	11 (12.4%)	0.35
Other**	73 (7.4%)	38	22	13
Not reported	3	1	1	1

p value is for overall chi-square and not for post hoc comparisons. Bonferroni correction was applied for post hoc comparisons (see Supplemental Materials).

“Other” category involved mentions less than 1.0%.

Note. Statistically significant p‑values are shown in bold.

Some concerns varied significantly across age groups, particularly regarding menopause (X² (2, N = 980) = 182.9, p < 0.001), family/relationships (X² (2, N = 980) = 9.8, p = 0.007), career/employment (X² (2, N = 980) = 22.2, p < 0.001), memory (X² (2, N = 980) = 25.5, p < 0.001), and sexual health (X² (2, N = 980) = 7.9, p = 0.02). Post hoc comparisons (see Supplemental Materials: A) revealed that concerns about menopause were most prevalent in the 45–55 age group (52.4%), dropped significantly in the 56–65 group (15.5%), and were absent in the 66–70 group. Family/relationship and caregiving concerns were significantly higher in the 45–55 age group (44.4%) than in older groups (34.9% in the 56–65 and 33.7% in the 66–70 groups). Career and retirement concerns were more prominent in the 45–55 and 56–65 groups (51.4% and 50.1%, respectively), but declined notably in the 66–70 group (24.7%), which may be associated with the transition from employment to retirement. Memory concerns were less prevalent in the 45–55 group (22.8%) than in the 56–65 (38.2%) and 66–70 groups (33.7%). Lastly, sexual health concerns were more common in the 45–55 group (27.4%), than in the 56–65 (19.6%) and 66–70 groups (20.2%).

Health and wellness concerns

The top reported health and wellness concerns were weight management (42.1%), brain health and memory (32.3%), pain (30.7%), and emotional and mental health (29.9%) (Table 3). Variations by age group were noted for weight management (X² (2, N = 980) = 10.9, p = 0.004), brain health and memory (X² (2, N = 980) = 16.0, p < 0.001), emotional/mental health (X² (2, N = 980) = 22.1, p < 0.001), bone health (X² (2, N = 980) = 12.0, p = 0.002), vulva/vaginal/dryness (X² (2, N = 980) = 5.8, p = 0.05), and hormonal replacement (X² (2, N = 980) = 25.0, p < 0.001).

Table 3.

Health and wellness concerns by stage of life (midlife).

Health and wellness concern	n (%)				p *
Health and wellness concern	Total (N = 980)	45–55 years (n = 504)	56–65 years ( n = 387)	66–70 years ( n = 89)	p *
Weight management	413 (42.1%)	224 (44.4%)	166 (42.9%)	23 (25.8%)	0.004
Brain health and memory	317 (32.3%)	136 (27.0%)	141 (36.4%)	40 (44.9%)	<0.001
Pain (e.g. joint, menstrual, migraines)	301 (30.7%)	154 (30.6%)	120 (31.0%)	27 (30.3%)	0.99
Emotional/mental health	293 (29.9%)	184 (36.5%)	86 (22.2%)	23 (25.8%)	<0.001
Heart health	225 (23.0%)	109 (21.6%)	89 (23.0%)	27 (30.3%)	0.2
Sleep changes	224 (22.9%)	114 (22.6%)	88 (22.7%)	22 (24.7%)	0.91
Cancer prevention	148 (15.1%)	70 (13.9%)	69 (17.8%)	9 (10.1%)	0.1
Bone health	144 (14.7%)	56 (11.1%)	68 (17.6%)	20 (22.5%)	0.002
Vision	107 (10.9%)	52 (10.3%)	44 (11.4%)	11 (12.4%)	0.79
Sexual relations	93 (9.5%)	58 (11.5%)	30 (7.8%)	5 (5.6%)	0.07
Bladder/urinary symptoms	91 (9.3%)	44 (8.7%)	38 (9.8%)	9 (10.1%)	0.82
Vulva/vaginal/vaginal dryness	86 (8.8%)	34 (6.7%)	44 (11.4%)	8 (9.0%)	0.05
Breast health	79 (8.1%)	47 (9.3%)	24 (6.2%)	8 (9.0%)	0.22
Hormonal replacement	74 (7.6%)	58 (11.5%)	16 (4.1%)	0	<0.001
Diabetes prevention	49 (5.0%)	23 (4.6%)	23 (5.9%)	3 (3.4%)	0.49
Hearing	46 (4.7%)	14 (2.8%)	22 (5.7%)	10 (11.2%)	–
Addiction (e.g. food, substance use, gambling)	36 (3.7%)	24 (4.8%)	10 (2.6%)	2 (2.2%)	–
Abnormal/irregular vaginal bleeding	36 (3.7%)	33 (6.5%)	2 (.5%)	1 (1.1%)	–
Autoimmune/chronic diseases	29 (3.0%)	12 (2.4%)	15 (3.9%)	2 (2.2%)
Staying active/stamina	12 (1.2%)	4 (0.8%)	7 (1.8%)	1 (1.1%)	–
Injuries/falls/wear and tear	9 (1.0%)	4 (0.8%	5 (1.3%)	0	–
Digestive/gut health (e.g. IBS)	9 (1.0%)	6 (1.2%)	2 (.5%)	1 (1.1%)	–
Other**	47 (4.7%)	24	18	5
Not reported	29	14	13	2

p value is for overall chi-square and not for post hoc comparisons. Bonferroni correction was applied for post hoc comparisons (see Supplemental Materials). Comparisons were made for concerns with more than 5.0% mention.

“Other” category involved mentions less than 1.0%.

Note. Statistically significant p‑values are shown in bold.

Post hoc comparisons (see Supplemental Materials: B) showed that weight management was a greater concern for women aged 45–55 (44.4%) and 56–65 (42.9%), than for those aged 66–70 (25.8%). Concerns about brain health and memory were more prevalent among women aged 66–70 years (44.9%) and 56–65 (36.4%), than those aged 45–55 (27.0%). Emotional and mental health concerns were significantly more common among women aged 45–55 (36.5%) than among those aged 56–65 (22.2%). Bone health concerns were reported more frequently by older women (66–70 years, 22.5%; 56–65 years, 17.6%), than by younger women (45–55 years, 11.1%). Hormone replacement therapy was a greater concern for women aged 45–55 (11.5%), than for those aged 56–65 years (4.1%), with none reported among those aged 66–70. While concerns about vulvar and vaginal dryness were more frequent among women aged 56–65 (11.4%) than those aged 45–55 (6.7%) and 66-70 (9.0%), these differences were not statistically significant after Bonferroni correction (likely due to sample size).

Use of health service and supports, and satisfaction

Less than one-half of the women surveyed (42.1%, n = 413) reported seeking care for a specific health concern, and 28.6% (n = 280) expressed general health concerns or questions about their current stage of life and desired additional education or information. A small proportion (8.6%, n = 84) were unsure where to seek care for specific concerns, and 3.3% (n = 32) reported feeling uncomfortable reaching out for care despite having concerns. No significant differences were found between age groups, χ²(8) = 7.30, p = 0.505 (see Supplementary Materials: C).

Women surveyed reported accessing various professionals, services, and supports over the past 2 years, with their family or walk-in doctor (96.5%) and dentist (81.9%) being the most commonly utilized. Additionally, 73.8% of respondents relied on family and friends for support (Table 4).

Table 4.

Professionals, services, and/or support accessed in the past 2 years (N = 980).

Professionals, services, and/or support accessed in the past 2 years	n (%)
Family doctor/Walk-in	946 (96.5%)
Dentist	803 (81.9%)
Family/friends	723 (73.8%)
Pharmacist	498 (50.8%)
Fitness/yoga/dance	469 (47.9%)
Physiotherapist	456 (46.5%)
Other MD specialists	427 (43.6%)
Counsellor/therapists/psychologist	259 (26.4%)
Chiropractor	247 (25.2%)
Gynecologist	194 (19.8%)
Personal trainer	165 (16.8%)
Naturopath	136 (13.9%)
Traditional Chinese med/acupuncture	127 (13.0%)
Community group	110 (11.2%)
Spiritual leader/group	103 (10.5%)
Massage therapist	83 (8.5%)
Support group	78 (8.0%)
Nutritionist/dietitian	71 (7.2%)
Life coach/mentor/career coach/advisor	64 (6.5%)
Registered nurse	60 (6.1%)
Nurse practitioner	54 (5.5%)
Osteopath	11 (1.1%)
Other*	28 (2.9%)
Not reported	3

“Other” category involved mentions less that 1.0%.

On average, women reported using 6.2 sources of professional services or support in the past 2 years (95% CI: [6.2, 6.4]), ranging from zero to 17 sources, with a median of 6.0. A one-way ANOVA showed a statistically significant difference in the number of services used across age groups, F(2, 977) = 6.18, p = 0.002. Post hoc comparisons with Bonferroni correction revealed that the 45–55 age group (M = 6.45, SD = 2.65) used significantly more services than the 66–70 group (M = 5.48, SD = 2.40), with a mean difference of 0.97 (p = 0.002). No significant differences were found between the 45–55 and 56–65 groups (mean difference = 0.31, p = 0.190), or between the 56–65 and 66–70 groups (mean difference = 0.65, p = 0.081).

Satisfaction and unmet needs

Women surveyed reported varying levels of satisfaction with professional services or support. Over one-half of respondents across all age groups (58.9%, n = 577) expressed satisfaction, though gaps remain, with 37.4% (n = 367) “somewhat satisfied,” and 3.4% (n = 33) “dissatisfied.” Satisfaction was slightly higher among older age groups, with 64.0% (n = 57) of women aged 66–70 and 63.0% (n = 244) of women aged 56–65 reporting satisfaction, than 54.8% (n = 577) in the 45–55 group. However, these differences were not statistically significant (χ²(4, N = 980) = 7.43, p = 0.115).

Among respondents who were not fully satisfied with services, 324 provided open-text survey responses describing their unmet needs. The majority were aged 45–55 (55.6%), followed by 56–65 (35.8%) and 66–70 (8.6%). Most lived in the Vancouver Lower Mainland region (83.4%), and the majority identified as European (80.6%). These distributions are comparable to the larger survey sample (see Table 1). Thematic analysis of these comments revealed several recurring issues, outlined below.

Barriers to accessing care

Long wait times, limited availability of health care providers, and brief appointments were frequently cited as obstacles to adequate care (n = 60, 18.5%). Some respondents also cited a lack of continuity due to not having a family doctor and worried that their reliance on walk-in clinics compromised ongoing monitoring of their health (n = 30, 9.3%). Other access issues included difficulties in obtaining referrals, accessing care, or knowing where to seek services (n = 29, 9.0%).

“The impossibility of finding a family doctor combined with the inadequate service of a walk-in clinic and their lack of care and continuity have made me feel extremely marginalized by the medical system and unworthy of care.” (Age 45–55)

“There are no family doctors and as a result no specialists available to me. I haven’t had a check-up in years. I am trying to get a family doctor and am on a waiting list.” (Age 56-65)

Other barriers contributing to their unmet needs included financial constraints, such as lack of employment health insurance to cover services not included in universal health care (e.g. physiotherapy, counseling) (n = 34, 10.5%). Barriers arising from the demands of daily life, such as caring for teens/adult children, ailing partners, aging parents, and managing challenging careers were also mentioned. Respondents noted that these commitments left them with insufficient time to attend to their own health, despite a greater need for support during this period (n = 13, 4.0%).

“. . .I have ailing parents, a challenging career and sudden onset of menopausal challenges - this is the most challenging time of my life and I feel so unsupported and lost. . .” (Age 45-55)

Care quality concerns

Respondents highlighted several issues related to quality of care received, with many reporting that their health issues remained unresolved and describing treatments as unhelpful or inadequate (n = 83, 25.6%). Some respondents also expressed dissatisfaction with the lack of mental health support, noting that their psychological needs were often overlooked or that care was not trauma-informed (n = 16, 4.9%).

“Mostly variations on the theme of suboptimal mental health care/supports. Also, health services are rarely trauma informed, resulting in all kinds of avoidable barriers/ problems.” (Age 45–55)

The service delivery model was another area of concern—a few respondents expressed dissatisfaction with group-model care, a preference for a nurse practitioner model, or a desire for more virtual options (n = 7, 2.2%). Additionally, a few mentioned that lack of shared decision-making contributed to their dissatisfaction with the quality of care (n = 3, 0.9%).

Provider responsiveness issues

Some respondents expressed concerns about provider competency, noting difficulties with diagnosis and a lack of specialized knowledge in menopause, and midlife care (n = 44, 13.6%). Others highlighted dismissive and unresponsive care, where providers ignored symptoms, inadequately managed pain and/or failed to proactively address issues or provide follow-up (n = 26, 8.0%). Lastly, some reported negative experiences with providers, feeling that their care lacked respect, with instances of judgment, shaming, or discrimination (n = 19, 5.9%).

“GP not helpful with some concerns. Missed prolapse symptoms for almost 10 years. Diagnosed by different health professional and friend living with it.” (Age 56–65)

“. . .poor attitudes about fatness/larger bodies leads to shaming/judging.” (Age 45–55)

Lack of comprehensive and integrated care

Respondents expressed concerns about the lack of comprehensive, preventative, and holistic care (n = 55, 17.0%), noting that services often focused on immediate issues, while neglecting root causes. Frustration with overmedicalization and the absence of integrated approaches that support the whole person were contributed to unmet needs. A few of the respondents also noted the lack of personalized care, feeling that their unique needs were not adequately addressed (n = 3, 0.9%).

“Everything feels so fragmented, and even the role of primary care provider doesn’t have the time to take a holistic view on health issues. complementary therapies, mental health, fitness, reviewing risk don’t seem to have a place.” (Age 45–55)

Communication and information gaps

Unmet health care needs were also linked to poor communication, and limited access to information and resources, particularly on menopause, the aging process and clarity around what constitutes normal aging versus conditions needing further investigation (n = 25, 7.7%).

“We can’t ask what we don’t know. . .and sometimes I don’t know if my physical ailments are part of aging (normal) or if they’re a problem. . .” (Age 45–55)

Patient self-advocacy due to system gaps

Some respondents felt compelled to self- advocate in an unresponsive health care system (n = 23, 7.1%). They reported feeling unsupported, often managing their health by conducting their own research, relying on resources like Google, and navigating their care without adequate professional guidance—making access to reliable information all the more crucial. Several also voiced frustration, feeling abandoned by the system.

“I don’t have a family doctor. . .there is no continuity, no follow up and no one to help me manage pain. I am left to fend for myself, which is fine now but when I get older and start losing it ?” (Age 56–65)

“I am the master of my own destiny. I need to take ownership over my own health.” (Age 66–70)

Desired features of a dedicated midlife women’s health program

Respondents (n = 728) provided open-text responses envisioning essential features of a care program tailored to midlife women. These respondents were aged 45–55 (49.5%), 56–65 (41.3%), and 66–70 (9.2%), with most living in the Vancouver Lower Mainland (84.2%) and identifying as European (80.1%). Their profile was comparable with that of the larger survey cohort (see Table 1). Thematic analysis revealed several important themes reflecting their diverse priorities, outlined below.

Specific health support for midlife women

Respondents proposed a midlife women’s program that prioritizes health support across key areas: menopause gynecological and sexual health (n = 164, 22.5%), mental health (n = 142, 19.5%), fitness and bone health (n = 123, 16.9%), nutrition (n = 61, 8.4%), weight management (n = 45, 6.2%), brain health (n = 37, 5.1%), heart and stroke health (n = 34, 4.7%), and sleep (n = 26, 3.6%).

“Mental health is really important. I have found myself becoming more anxious and worrying unduly about family members. . .perhaps linked with retirement and difficulty finding things to do which make a difference and are worthwhile.” (Age 66–70)

Comprehensive and integrated care

Respondents also suggested that a midlife women’s program should emphasize a comprehensive, integrated approach, including preventative care with adequate diagnostics for early detection of illnesses (n = 126, 17.3%). They also advocated for a holistic, team-based model to treat the whole person and address the root causes of health issues (n = 63, 8.7%). Additionally, some stressed the importance of having a program designed by and for women, with female care providers who bring an understanding of aging needs (n = 18, 2.5%). Some interest was also shown in integrating alternative health interventions to reduce over-medicalization (n = 17, 2.3%).

“A wholistic approach to care that looks at the physical, emotional and social aspects of health rather than looking at each symptom in isolation.” (Age 45–55)

Access to barrier-free services and supports

Respondents highlighted the need for a midlife women’s program that ensures barrier-free access to services and support. They stressed the importance of continuous access to primary and specialized care, referrals, and follow-up (n = 80, 11.0%). Timely and flexible access was also essential, with respondents expressing the need for reduced wait-times, extended service hours, and quicker access through e-mail, phone, or virtual visits (n = 69, 9.5%). Removing additional barriers, such as allowing sufficient time during care appointments to address multiple health concerns (n = 22, 3.0%), ensuring care is available closer to home (n = 5, 0.7%), and providing access to affordable extended health care services (e.g. physiotherapy) and prescription drugs were also highlighted (n = 21, 2.9%). Respondents also called for alternative care models, such as hybrid (in-person/virtual) options, peer support, and health monitoring apps (n = 31, 4.3%). Access to community services was also deemed essential, particularly for affordable housing, transportation, and financial planning (n = 25, 3.4%). Assisted living and long-term planning, especially for those living alone or without caregivers or adult children, were also noted (n = 11, 1.5%).

“Start with access: I cannot find a primary care provider or team of any kind; when I found one, the clinic closed and didn’t even let me know; when I reach out, they are not accepting new patients; it is not always possible to take a half day off work to fit into the provider’s restrictive schedule. Make a clinic accessible (in all aspects of the word.” (Age 56–66)

Relational and inclusive care

Another key element identified by respondents for a midlife women’s program was the importance of relational care, with a strong focus on provider responsiveness and personalized support (n = 110, 15.1%). They valued providers who know them, listen attentively, ask questions, and engage in shared decision-making. Additionally, respondents emphasized the need to be treated as unique individuals, with respectful, compassionate, nonjudgmental providers who create a safe space for discussing private concerns.

“Having a doctor that knows you, cares about your long-term health not just getting you out the door in 15 minutes.” (Age 45–55)

Additionally, some respondents highlighted the need for inclusive and culturally sensitive care (n = 17, 2.3%), emphasizing safe, respectful care for all, including trans and queer individuals, people from diverse ethnic backgrounds, abilities, and body types. They also noted the importance of provider training in respectful environments, equity, diversity, and inclusion (REDI), as well as the availability of interpreters, diverse staff, and information in multiple languages to foster an inclusive and culturally safe environment.

“Needs to be queer-inclusive. The last program I went to treated lesbians as an outlier.” (Age 45–55)

Clear communication, information, and education

A key theme identified by respondents for a midlife women’s program was the need for clear communication and accessible information. They highlighted the importance of raising awareness about aging (n = 132, 18.1%), including physical changes and social transitions such as retirement and changes in family dynamics. Education on distinguishing normal aging from conditions requiring medical attention, along with strategies for healthy aging, were seen as essential. Some respondents called for accessible and inclusive health information (n = 110, 15.1%), recommending that information be available in plain language, large fonts, and culturally diverse formats. They also stressed the importance of delivering this information through multiple channels (e.g. online, print), and ensuring it is evidence-based and reliable.

“Proactively providing information. . .Frankly, I don’t know what I don’t know. . . I find myself wondering whether my health concerns are related to my age or not. For example, I have pain in my hands and fingers. Is this normal for my age? I’ve gained 10 lbs. Should I be concerned?” (Age 45–55)

Fostering community, self-care, and system navigation

Another recurrent theme was the importance of fostering community, promoting self-care and supporting system navigation. Respondents underscored the importance of reducing isolation and building connections through support groups and peer networks (n = 71, 9.8%). Promoting self-care and family caregiving support were also viewed as essential (n = 53, 7.3%), with respondents noting that they need to balance work, personal well-being, and caregiving responsibilities for teens/adult children, ailing partners, and/or aging parents. Lastly, a few of the respondents stressed the importance of advocacy, either by empowering women to advocate for themselves or by providing access to patient advocates and resources (n = 4, 0.5%).

“. . .I think connection is important for many women who are isolated. I have a great network, but I know lots of women who don’t, so group care and group support would be great.” (Age 56–65)

Discussion

This study provides insights into the health priorities, service use, and program preferences of midlife women in BC. Staying physically fit was the top priority across midlife stages. Health and wellness concerns most often included weight management, brain health and memory, pain and emotional and mental health, with notable variations across age groups. Concerns about menopause and mental health were more prominent earlier in midlife, while bone and brain health concerns were more frequently noted among older participants. These results align with findings from major cohort studies showing persistence of menopausal and chronic health issues across midlife.^2,6,7 These age-related variations are also consistent with research showing that body weight increases linearly from pre- to post-menopause, with the rate of change flattening 2 years after the final menstrual period.²⁸ Research also shows that bone loss begins before menopause but escalates in the post-menopausal years⁶ and that cognitive abilities decline after the menopause transition, compared with those before.²⁹ Evidence also indicates that women generally perform better than men on memory and processing speed at this life stage, but this advantage diminishes with age and has declined in more recent birth cohorts.³⁰ These demonstrate that midlife women’s priorities shift across the life stages, supporting the need for tailored programs that meet evolving needs.

Women in our study also reported high use of primary care, with many satisfied, but also noted gaps in access, coordination, communication, and provider knowledge specific to midlife, consistent with other BC research.⁷ Beyond findings on priorities and gaps, the most distinctive contribution of this study lies in documenting women’s vision for a dedicated program for midlife women in BC. Through synthesis of the women’s stated priorities, reported gaps, and their expressed program expectations, we identified several core components that can guide the design of such a program, described in the sections that follow. Importantly, many of these components (such as integrative and preventative care) are inherently flexible and can be applied across the different stages of midlife, ensuring the program remains responsive to women’s evolving needs.

Integrated, whole-person care

Our findings reflect the multifaceted and evolving needs of midlife women, which are often overlooked in standard health care, and point to a strong desire for a “whole-person approach” to care.^31,32 Women in our study framed their vision for a dedicated midlife program as integrated. They described fragmented pathways and short visits that focused on single immediate issues, while underlying causes were overlooked. There is a need to link menopause management with fitness, weight management, and bone and brain health, through coordinated and multidisciplinary approaches. Concerns about brain health or memory were commonly reported among our respondents and are also well documented in other studies.², ³³ Evidence also shows that physical activity can help protect brain health in perimenopause and early post-menopause.³⁴ In addition, combining hormone therapy and structured exercise has been found to enhance bone mineral density and contribute to mental well-being.³⁵ Although evidence indicates that menopause-related concerns are highly interconnected and benefit from integrated care, such approaches are not yet routinely implemented in clinical practice, underscoring their importance for program design.^36,37

Preventative care and early detection

Women in our study emphasized the importance of preventative approaches, particularly early detection of illnesses such as cancer and dementia, and regarded prevention as a central expectation of a dedicated program to support healthy aging. Participants in our study also highlighted fitness and weight management as key concerns, underscoring the need for prevention to also encompass lifestyle modifications. Research shows that midlife is a pivot window for preventive action, with studies recommending both lifestyle modifications and screening interventions at this stage.^38–40 Research further indicates that midlife women are highly motivated to take proactive measures to maintain positive mental health and physical functioning, reinforcing the need for preventative care to support healthier aging.⁴¹

Mental health as a priority

In our study, mood concerns, anxiety, and stress were central themes, particularly in the context of caregiving and work demands. Feelings of isolation were also reported, reinforcing the importance of connection and belonging in midlife health. These findings align with broader research showing loneliness as a predictor of poor health outcomes and of not aging well in women^42,43 and that midlife women experience high rates of depression, anxiety, and psychological distress, often intersecting with physical, hormonal, and social challenges.^44–47 Notably, Gnanasegar et al. found that 62% of women seeking specialized menopause care reported depressive symptoms.⁴⁸ Hence, mental health cannot be treated as secondary; any dedicated program for midlife women must position it as a core component of care.

Access that fits women’s lives

Women in our study commonly relied on family physicians and walk-in care but reported long waits, limited availability, lack of continuity and challenges with obtaining referrals. Some were unsure where to seek help or struggled to secure a family physician. Participants also emphasized the need for flexible care options that fit their lives and responsibilities, including virtual care, extended hours, and longer appointments that allow multiple concerns to be addressed. Financial barriers further restricted access, with participants reporting allied health as unaffordable. The HER-BC study quantified the economic burden of menopause care in BC, reporting an average of $900 annually in out-of-pocket expenses for services not covered by universal health care, underscoring the need of publicly accessible midlife services.⁷

These unmet needs echo broader research showing that access, timeliness, and affordability as major predictors of satisfaction among older adults.^49,50 Findings from Taylor-Swanson et al. reinforce these concerns.³² In their study, midlife women reported similar barriers to both conventional and integrative care and expressed strong interest in medical group-based models involving one or two health care providers alongside peers, offering longer discussions, and whole-person approaches. They also envisioned group-based models delivered virtually or in hybrid formats as a feasible way to overcome access barriers. Although in our study such models were not explored, they highlight promising directions for dedicated midlife programs to address persistent structural barriers and unmet needs. Group-based medical models have also been successfully adapted in cultural contexts among midlife women.⁵¹

Relational, personalized, and competent care

Women in our study emphasized the importance of being known, heard, and treated with respect. Provider responsiveness was seen as a key concern, with women reporting dismissive behavior, missed diagnoses, unresolved health issues, a lack of shared decision-making, and variable provider knowledge of midlife and menopause. These findings highlight the value of patient-centered care that prioritizes relationality, trust, effective communication, and collaboration.⁵² Relational care has been shown to improve health outcomes, fostering a strong patient-provider connection by balancing scientific practice with empathy and recognizing the personhood of both provider and patient in a respectful partnership.⁵³ The lack of provider responsiveness described by women may also reflect limited provider knowledge, which aligns with research showing that gaps in understanding of menopause can delay recognition of the transition and effective symptom management.⁵⁴

Respondents also emphasized that a midlife women’s program should prioritize personalized care as a central feature. Personalized care moves away from prescriptive, one-size-fits-all models, by encouraging providers to work with “women in context” and tailor care to their specific needs.⁵⁵ This includes recognizing life changes during midlife, such as shifting caregiving responsibilities, career trajectories, and social roles, which are often linked to stress and loneliness.⁴³ It also means ensuring women are supported not only in clinical management but in navigating these transitions.⁵⁶ A dedicated midlife program should make relationship-based practice an explicit standard by investing in provider training on midlife and menopause, respectful communication, culturally safe and gender-inclusive care, and by designing visits that allow enough time for connection and shared decision making.

Clear information and navigation

In our study, women emphasized the critical need for accessible, plain-language, and reliable information on healthy aging. They expressed uncertainty about which changes in midlife are “normal” and which warrant assessment or treatment. In light of these information gaps, many of the participants felt unsupported in navigating their health and emphasized a need for self-advocacy, which in turn led them to rely on Google and other online resources to manage their health without professional oversight. These findings echo results from the Australian Women and Digital Health Project, which found that women highly valued search engines and social media platforms for locating information for both themselves and in their caregiving roles.⁵⁷ In this study, women reported that these digital tools enhanced their sense of knowledge, agency, and control, but also described frustration when information was confusing or unreliable. Hence, over-reliance on such resources carries risks, as distinguishing trustworthy and unreliable information can be challenging, especially given the rapid spread of misinformation on social media and the availability of unregulated products for menopause managment.^58,59

Any midlife program for women should include or link to curated information hubs that offer plain-language, trustworthy resources. For example, the Menopause Foundation of Canada⁶⁰ and the Women’s Mid-Life Health Program in Saskatchewan offers a comprehensive online resource section with curated information.⁶¹ Importantly, providers play a central role in directing women to reliable resources and contextualizing information to their individual health needs.⁵⁴

Community and peer connection

Reducing isolation through peer connections and support was frequently mentioned by respondents as an essential feature of a comprehensive midlife program. Participants emphasized the value of having structured opportunities to connect with others in similar life stages, particularly for those without strong personal or community networks. Peer support was viewed as ways to foster belonging and shared learning. Hence, programs should embed community and peer-based components alongside clinical services. Evidence from the literature also points to the potential of group-based and peer support models to reduce distress, loneliness, and help normalize the experience of menopause.^32,62 Menopause Cafés provide one example of a community-based intervention in which volunteers host informal gatherings where people come together over tea and cake to “talk menopause.”⁶³ The value of this model lies in its ability to reduce loneliness through companionship, counter stigma, validate experiences, and empower participants to seek further information and care. Integrating such approaches with clinical services can broaden midlife care beyond clinical practice, helping to address key social determinants of health, such as isolation and the psychosocial challenges of role transitions.

Current program development in British Columbia

In many respects, the vision articulated by women in our study already has a foothold in BC. BCW recently launched the Complex Menopause Clinic, which offers both in-person and virtual care for people with challenging menopausal symptoms that could not be managed in standard settings. This clinic, informed in part by our survey findings and other consultative work, integrates specialist consultation, counselling, medication management, and referrals across breast health, bone health, and cardiovascular and metabolic services. It also provides patient education through webinars on topics such as mental health, sleep, bone health, memory, weight management, fitness and work and career issues in midlife.

The clinic is part of a broader midlife women’s health strategy at BCW. The challenge moving forward is to ensure that this strategy expands beyond complex symptom management, adopting a comprehensive midlife mandate that connects seamlessly with preventative, relational, and community-based supports prioritized by women in our study, while remaining responsive to evolving needs across the different life stages of midlife.

Limitations

One limitation of this study is the lack of explicit gender identity criteria and the absence of a gender question, which limited our ability to fully understand the diversity of the sample. This, along with noninclusive recruitment language likely resulted in a predominance of cisgender women among the respondents, limiting the generalizability to trans and nonbinary individuals. Additionally, because we relied on a convenience sample, participants were predominantly from urban areas and ethnically homogenous, mostly of European descent, and the lack of socioeconomic data further limits generalizability to more culturally diverse, racialized, rural, and socioeconomically varied populations. Although we aimed to survey broadly across the province and did recruit participants from multiple regions, in-person efforts (e.g. posters) were concentrated in the Vancouver Lower Mainland, likely contributing to an overrepresentation of urban perspectives. As such, our findings may not be fully representative of the broader BC population. Further research is needed to better understand the priorities of underrepresented groups, and future programs should be tailored to reflect cultural contexts, geographic access challenges, and systemic inequities.

Another limitation is that we did not use any standardized survey tools, like symptom checklists, as our focus was not on qualifying symptom burden, but on capturing broader self-reported midlife priorities and program needs. Content validity was established through literature synthesis, expert review and consultation with midlife women. Moreover, because this was a cross-sectional, self-reported survey, the findings are descriptive in nature and do not allow for causal inference. Self-reported data may also be subject to recall and social desirability bias, with no clinical assessments conducted to verify health conditions. Nonetheless, the study’s aim was to capture women’s perceptions and lived experiences to inform program design, and the consistency of our findings with existing literature increases confidence in the results. In addition, since our study did not include male participants, we cannot determine whether the identified priorities (particularly among older participants) are unique to women or reflect broader aging processes common to both sexes. Further research is needed.

Another consideration is the timing of our data collection. Because the survey was conducted in 2019, prior to the COVID-19 pandemic, the findings may not fully reflect shifts in behaviors or attitudes since, such as increased use of virtual care.⁶⁴ Nonetheless, our results align with more recent research broadly and in BC, suggesting that core priorities and perceptions of aging well have remained relatively stable over time.^7,31,32 At the same time, a key strength of our study is its broad focus beyond menopausal symptoms, which provides new insights into the wider health and priorities of midlife women in BC and their vision for a dedicated program. Future qualitative research can complement these findings and further deepen understanding of women’s program needs.

Conclusion

This study highlights the health priorities, service use, and program preferences of midlife women in BC, demonstrating that their needs extend beyond menopause symptom management to encompass interconnected priorities across physical and mental health, as well as social and relational domains. Their vision of a dedicated midlife program offers insights that can guide the development of comprehensive care that integrates services across domains; emphasizes prevention, early detection, and mental health; improves access and affordability; strengthens provider competence and responsiveness; and connects women with trustworthy resources and supportive communities to promote healthy aging. Future research can further support the continued refinement of programs tailored to this stage of life.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261419909 – Supplemental material for Navigating midlife: Priorities and program needs of women in British Columbia

Supplemental material, sj-docx-1-whe-10.1177_17455057261419909 for Navigating midlife: Priorities and program needs of women in British Columbia by Shabnam Ziabakhsh, Astrid Christoffersen-Deb, Ann Pederson, Allie Cui, Caylee Raber, Nadia Beyzaei and Phyllis With in Women's Health

Supplemental Material

sj-pdf-2-whe-10.1177_17455057261419909 – Supplemental material for Navigating midlife: Priorities and program needs of women in British Columbia

Supplemental material, sj-pdf-2-whe-10.1177_17455057261419909 for Navigating midlife: Priorities and program needs of women in British Columbia by Shabnam Ziabakhsh, Astrid Christoffersen-Deb, Ann Pederson, Allie Cui, Caylee Raber, Nadia Beyzaei and Phyllis With in Women's Health

Footnotes

Acknowledgements

The authors wish to acknowledge the following individuals for their valuable support and contributions to our research: Cheryl Davies, Edwina Houlihan, Ronnalea Hamman, Dr. Stephanie Rhone, Sabina Dobrer, Dr. Kerstin Gustafson, Debra Anne Marleau, BC Women’s Health Foundation, and design research assistants Eugenie Cheon, and Katherine McDonald from the Health Design Lab at Emily Carr University of Art + Design.

ORCID iDs

Shabnam Ziabakhsh

Caylee Raber

Ethical considerations

This study was approved by the University of British Columbia Children’s and Women’s Research Ethics Board (REB) (H19-00180) and the Emily Carr University’s REB. The study was conducted in accordance with Canada’s Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2).

Consent to participate

The survey was anonymous and conducted online. Consent was implied through completion and submission, as approved by the REB.

Author contributions

Shabnam Ziabakhsh: Formal analysis; Data curation; Writing—original draft; Investigation; Validation.

Astrid Christoffersen-Deb: Conceptualization; Investigation; Supervision; Project administration; Methodology; Writing—review and editing.

Ann Pederson: Investigation; Supervision; Writing—review and editing.

Allie Cui: Investigation; Formal analysis; Validation; Writing—original draft.

Caylee Raber: Investigation; Writing—review and editing.

Nadia Beyzaei: Investigation; Visualization; Writing—review and editing.

Phyllis With: Investigation; Writing—review and editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data used are not publicly available. Further inquires can be directed to the corresponding author.

Supplemental material

Supplemental material for this article is available online.

References

Lachman

Teshale

Agrigoroaei

Midlife as a pivotal period in the life course: balancing growth and decline at the crossroads of youth and old age. Int J Behav Dev 2015; 39: 20–31.

Islam

Bond

Ghalebeigi

, et al. Prevalence and severity of symptoms across the menopause transition: cross-sectional findings from the Australian Women’s Midlife Years (AMY) Study. Lancet Diabetes Endocrinol 2025; 13: 765–776.

Thu

Logan

Lim

, et al. The Integrated Women’s Health Programme (IWHP): a study of key health issues of midlife Singaporean women. Int J Epidemiol 2018; 47: 389–390f.

Costanian

McCague

Tamim

Age at natural menopause and its associated factors in Canada: cross-sectional analyses from the Canadian Longitudinal Study on Aging. Menopause 2018; 25: 265–272.

Santoro

Epperson

Mathews

SB.

Menopausal Symptoms and Their Management. Endocrinol Metab Clin North Am 2015; 44: 497–515.

El Khoudary

Greendale

Crawford

, et al. The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause 2019; 26: 1213–1227.

Brotto

Adshade

Booth

, et al. The Health and Economics Research on Midlife Women in BC (HER-BC) Report. 2024.

Ward-Ritacco

Greaney

Clark

, et al. The longitudinal association between physical activity and physical function in older women. Front Sports Act Living 2022; 4: 879025.

Samieri

Sun

Townsend

, et al. The relation of midlife diet to healthy aging: a cohort study. Ann Intern Med 2013; 159: 584–591.

10.

Anupama

Noronha

Acharya

KKV

, et al. Effect of lifestyle modification intervention programme on bone mineral density among postmenopausal women with osteoporosis. Sultan Qaboos Univ Med J 2023; 23: 387–393.

11.

Xiaoya

Junpeng

, et al. Effect of different types of exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis. Sci Rep 2025; 15: 94510.

12.

Shou

Zhang

, et al. Efficacy of cognitive therapy and behavior therapy for menopausal symptoms: A systematic review and meta-analysis. Psychol Med 2022; 52: 433–445.

13.

Vinogradova

Iyen

Masud

, et al. Discontinuation of menopausal hormone therapy and risk of fracture: nested case-control studies using routinely collected primary care data. Lancet Healthy Longev 2025; 6: 100729.

14.

Cosco

Prina

Perales

, et al. Operational definitions of successful aging: a systematic review. Int Psychogeriatr 2014; 26: 373–381.

15.

Woods

Rillmamas-Sun

Cochrane

, et al. Aging well: observations from the women’s health initiative study. J Gerontol A Bio Sci Med Sci 2016; 71: S3–S12.

16.

Tannenbaum

Nasmith

Mayo

Understanding older women’s health care concerns: a qualitative study. J of Women Aging 2003; 15(1): 3–16.

17.

Avis

Colvin

Hess

, et al. Midlife factors related to psychological well-being at an older age: study of women’s health across the nation. Journal of Women’s Health. J Womens Health 2021; 30: 332–340.

18.

Statistics Canada. Canada Census 2016 Profile: British Columbia and Canada. Report, Statistics Canada, 2016.

19.

Saadedine

Safwan

Kapoor

, et al. Association of informal caregiving and menopause symptoms in midlife women: a cross-sectional study. Mayo Clin Proc 2025; 100: 42–51.

20.

Wood

McCarthy

Pitt

, et al. Women’s experiences and expectations during the menopause transition: a systematic qualitative narrative review. Health Promot Int 2025; 40: daaf005.

21.

Jaspers

Daan

van Dijk

, et al. Health in middle-aged and elderly women: a conceptual framework for healthy menopause. Maturitas 2015; 81: 93–98.

22.

Enriquez

Lackey

Witt

Health concerns of mature women living with HIV in the midwestern United States. J Assoc Nurses AIDS Care 2008; 19: 37–46.

23.

Seelman

Adams

Poteat

Interventions for healthy aging among mature Black lesbians: Recommendations gathered through community-based research. J Women Aging 2017; 29: 530–542.

24.

Welner

Simon

Welner

Maximizing health in menopausal women with disabilities. Menopause 2002; 9: 208–219.

25.

Schafter

Graham

JW.

Missing data: Our view of the state of the art. Psychol Methods 2002; 7: 147–177.

26.

Thomas

DR.

A general inductive approach for analyzing qualitative evaluation data. Am J Eval 2006; 27: 237–246.

27.

Viera

Garrett

JM.

Understanding interobserver agreement: the kappa statistic. Fam Med 2005; 37: 360–363.

28.

Greendale

Jiang

Karlamangla

AS.

Changes in body composition and weight during the menopause transition. JCI Insight 2019; 4: e124865.

29.

Guo

Gross

, et al. Age at menopause and cognitive function and decline among middle-aged and older women in the China Health and Retirement Longitudinal Study (CHARLS). Alzheimers Dement 2025; 21: e15780.

30.

Nooyens

ACJ

Wijnhoven

HAH

Schaap

, et al. Sex Differences in Cognitive Functioning with Aging in the Netherlands. Gerontology. Gerontology 2022; 68: 999–1009.

31.

Johnson

Jou

Upchurch

DM.

Psychological distress and access to care among midlife women. J Aging Health 2020; 32: 317–327.

32.

Taylor-Swanson

Stoddard

Fritz

, et al. Midlife women’s menopausal transition symptom experience and access to medical and integrative health care: informing the Development of MENOGAP. Glob Adv Integr Med Health 2024; 13: 27536130241268355.

33.

Conde

Verdade

Valadares

ALR

, et al. Menopause and cognitive impairment: a narrative review of current knowledge. World J Psychiatry 2021; 11: 412–428.

34.

Faridi

Daun

Dhruva

, et al. Movement and brain health in perimenopausal and early postmenopausal females: a scoping review. Maturitas 2025; 202: 108747.

35.

Platt

Bateman

Bakour

Impact of menopause hormone therapy, exercise, and their combination on bone mineral density and mental wellbeing in menopausal women: a scoping review. Front Reprod Health 2025; 7: 1542746.

36.

Davis

Magraith

Advancing menopause care in Australia: barriers and opportunities. Med J Aust 2023; 218: 500–506.

37.

Barber

Charles

Barriers to accessing effective treatment and support for menopausal symptoms: a qualitative study capturing the behaviours, beliefs and experiences of key stakeholders. Patient Prefer Adherence 2023; 15: 2971–2980.

38.

Arigo

Romano

Pasko

, et al. A scoping review of behavior change techniques used to promote physical activity among women in midlife. Front Psychol 2022; 13: 855749.

39.

Chelmow

Gregory

Witkop

, et al. Preventing obesity in midlife women: a recommendation from the women’s preventive services initiative. Ann Intern Med 2022; 175: 1305–1309.

40.

Ritchie

Bridgeman

Gregory

, et al. The PREVENT dementia programme: baseline demographic, lifestyle, imaging and cognitive data from a mid-life cohort study investigating risk factors for dementia. Brain Commun 2024; 6: fcae189.

41.

Kopanidis

Reid

‘Looking forward’: an actionable framework for proactive health and well-being behaviours in Australian midlife women. Health Promot J Austr 2024; 35: 794–803.

42.

Beutel

Klein

EM.

Brähler

, et al. Loneliness in the general population: prevalence, determinants and relations to mental health. BMC Psychiatry 2017; 17: 97.

43.

Liberatore-Maguire

Devlin

Fisher

, et al. The unseen epidemic: trauma and loneliness in urban midlife women. Womens Midlife Health 2022; 8: 11.

44.

Blanchflower

Oswald

AJ.

Antidepressants and age: a new form of evidence for U-shaped well-being through life. J Econ Behav Organ 2016; 127: 46–58.

45.

Brody

Pratt

Hughes

JP.

Prevalence of depression among adults aged 20 and over: United States, 2013-2016. Report, Centres for Disease Control and Prevention, 2018.

46.

Shifren

Gass

and Group NRfCCoMWW. The North American Menopause Society recommendations for clinical care of midlife women. Menopause 2014; 21: 1038–1062.

47.

Kravitz

Colvin

Avis

, et al. Risk of high depressive symptoms after the final menstrual period: the Study of Women’s Health Across the Nation (SWAN). Menopause 2022; 29: 805–815.

48.

Gnanasegar

Wolfman

Galan

, et al. Does menopause hormone therapy improve symptoms of depression? Findings from a specialized menopause clinic. Menopause 2024; 31: 320–325.

49.

Osborn

Moulds

Squires

, et al. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff 2014; 33: 2247–2255.

50.

Stepurko

Pavlova

Groot

Overall satisfaction of health care users with the quality of and access to health care services: a cross-sectional study in six Central and Eastern European countries. BMC Health Serv Res 2016; 16: 342.

51.

Ziabakhsh

Pederson

Prodan-Bhalla

, et al. Women-centered and culturally responsive heart health promotion among indigenous women in Canada. Health Promot Pract 2016; 17: 814–818.

52.

Gagliardi

Nyhof

Dunn

, et al. How is patient-centred care conceptualized in women’s health: a scoping review. BMC Womens Health 2019; 19: 156.

53.

Soklaridis

Ravitz

Adler Nevo

, et al. Relationship-centred care in health: a 20-year scoping review. Patient Exp J 2016; 3: 130–145.

54.

Aninye

Lintz

Chinnappan

, et al. Menopause preparedness: perspectives for patient, provider, and policymaker consideration. Menopause 2021; 28: 1186–1191.

55.

Pederson

Izadnegahdar

Humphries

, et al. Pioneering women-centred heart health promotion. In: Greaves

Pederson

Poole

(eds). Making it better: Gender transformative health promotion for women. Canadian Scholars Press, 2014.

56.

Infurna

Gerstorf

Lachman

ME.

Midlife in the 2020s: Opportunities and challenges. Am Psychol 2020; 75: 470–485.

57.

Lupton

How women use digital technologies for health: qualitative interview and focus group study. J Med Internet Res 2019; 21: e11481.

58.

Starcevic

Keeping

Dr.

Google under control: how to prevent and manage cyberchondria. World Pychiatry 2023; 22: 233–234.

59.

Gunter

Addressing the challenges of online misinformation and unregulated products in the clinical management of menopause. Obstet Gynecol 2025; 146(2): 189–194.

60.

Menopause Foundation of Canada. What everyone should know about menopause. https://menopausefoundationcanada.ca/resources/menopause-what-everyone-should-know/ (n.d., accessed 17 December 2025).

61.

Women’s Mid-Life Health Program. Support. Inform. Inspire, https://womensmidlifehealth.ca (n.d., accessed 17 December 2025).

62.

Cowell

Gilmour

Atkinson

Support mechanisms for women during menopause: perspectives from social and professional structures. Women 2024; 4: 53–72.

63.

Weiss

Menopause Cafés: it’s good to talk. Maturitas 2019; 132: 79–80.

64.

Bhatia

Chu

Pang

, et al. Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study. CMAJ Open 2021; 9: E107–E114.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.05 MB

0.16 MB