Socioeconomic and Lifestyle Factors Affecting Age at Natural Menopause: Global Systematic Review Original paper

What was reviewed?

This systematic review and meta-analysis synthesized data from 46 community-based studies across 24 countries, assessing the influence of socioeconomic position (SEP) and lifestyle factors on age at natural menopause (ANM). The review sought to determine overall mean ANM globally, compare regional differences, and quantify the impact of SEP (education, occupation, income) and modifiable lifestyle factors (smoking, body mass index [BMI], and physical activity) on menopausal timing. The meta-analyses incorporated both published and previously unpublished results from the Australian Longitudinal Study on Women’s Health (ALSWH), applying rigorous inclusion criteria and harmonizing variable definitions to maximize comparability.

Who was reviewed?

The review included a diverse range of women from 46 population-based cohorts across six continents, with total sample sizes in the tens of thousands. Study populations varied in age, ethnicity, and region (Africa, Asia, Australia, Europe, Latin America, Middle East, USA). All included studies excluded women with surgical menopause and largely defined natural menopause according to World Health Organization criteria. Most studies were cross-sectional, with some prospective cohorts; ethnic details were inconsistently reported. The ALSWH sample (n≈7,500) contributed prospective, nationally representative data from Australia.

Most important findings

The pooled mean age at natural menopause was 48.8 years, but substantial regional variation was noted: ANM was lowest in African, Latin American, Asian, and Middle Eastern countries, and highest in Europe, Australia, and the USA. Socioeconomic indicators showed a clear, dose-response association with ANM. Higher education and occupation levels were significantly associated with later menopause, and these effects were more pronounced in developed regions. Smoking was robustly associated with earlier menopause, advancing ANM by nearly one year, with a stronger effect in developed regions. Overweight status and moderate to high physical activity were weakly associated with later ANM, but findings were inconsistent and attenuated after adjustment for confounders. No consistent association was observed between income and ANM. Importantly, the review highlights that region, SEP, and lifestyle factors together explained a substantial portion of the observed heterogeneity in menopausal timing.

Key implications

This review confirms that ANM is not only regionally variable but also socially and behaviorally patterned. Lower education and occupation levels and smoking are associated with earlier menopause, suggesting that modifiable social and lifestyle factors substantially influence reproductive aging and may affect long-term health risks (e.g., osteoporosis, cardiovascular disease). These findings underscore the importance of incorporating SEP and lifestyle factors in clinical risk stratification for postmenopausal health. For microbiome research and clinical databases, the strong associations of SEP and smoking with ANM suggest these variables should be considered key contextual factors when interpreting or designing studies on menopausal microbiome signatures. The inconclusive associations for BMI and physical activity highlight the need for further, harmonized investigations, ideally using pooled individual-level data from prospective cohorts.