From maca to marijuana: cultural influences on joint pain symptoms and management in urban perimenopausal and early postmenopausal Latinas

Design

We conducted a descriptive qualitative study guided by a feminist approach in which researchers emphasize the participants’ views, perspectives, and experiences of menopause as well as the interaction between gender and other contextual factors that might influence participant experiences.^20,22,23 The focus group method, which brings participants together in small groups to discuss a specific topic of common interest, was chosen as the qualitative approach because of its successful use with women on topics related to women’s health.²⁴

Setting and participants

After approvals by the institutional review board of Columbia University and the Community Engagement Research Center of the Irving Institute for Clinical and Translational Research, participants were drawn from an active volunteer community of women residing immediately surrounding our medical center where according to zip code demographics, the majority of residents are medically underserved, are largely Latino (71%), recent immigrants (51%), and primarily from the Dominican Republic and Puerto Rico.²⁵ Participants were recruited through flyers and mailings distributed to the Community Engagement Research Center core’s registry of community volunteers. Flyers were placed in buildings throughout the Columbia Medical Center as well as affiliated clinics, and schools (ie, school of medicine, nursing, dentistry).

Women between the ages of 45 and 60 years were eligible for inclusion if they: 1) self-identified as Hispanic/Latina; 2) were peri- or early postmenopausal based on reported menstrual irregularity or last menstrual period 3 months to 5 years ago; 3) were experiencing new-onset or worsening musculoskeletal pain/stiffness of the neck, shoulder, fingers, back, hips, knees, or ankles; 4) were not taking hormone therapy or birth control pills; 5) able to read and speak conversational English; and 6) willing to speak about health issues with a group of other research volunteers with a similar background. We included women who were early postmenopausal due to documented data in the Study of Women’s Health Across the Nation (SWAN) showing menopause symptoms can extend to 5-year from last menstrual period (LMP). Women were excluded if currently suffering from other conditions such as cancer or recent physical injury, which could impact the course of pain or pain management. Women were also excluded if they reported other comorbid conditions with potential effects on pain (eg, diabetes, depression), or used antidepressants in the last 6 months.

Interested participants contacted the study team by telephone or email to assess eligibility and review the study protocol. Eligible participants were invited to a focus group session in an accessible conference room at the Community Partnership for Health, a resource of Columbia University’s Irving Institute for Clinical and Translational Research. Written informed consent was obtained by the moderator before the focus group discussion.

Data collection procedures

Thirteen volunteers participated in one of five focus groups ranging in size from one to four individuals held between January 2014 and December 2014. Out of respect for those individuals who attended, there was no minimum number required for the interview. At each session, one or two “no-shows” were common due to childcare problems, difficulties with transportation, or work schedules, thus contributing to the very small size of some groups in two cases. Before the start of the focus group interview, an informed consent process was completed, and an investigator-developed questionnaire was used to collect information on demographics (eg, age, Latina background, employment), clinical history, and pain symptoms. Participants self-reported their height and weight, which was used to calculate BMI in kg/m². Pain was assessed using the short form of the Brief Pain Inventory, which consisted of a front and back body diagram to identify 14 pain locations, four pain severity items (average level, current level, worst and least in the last 24 hours) and seven pain interference items rated on 0 (least) to 10 (worst) scales (general activity, mood, walking, relations with other people, sleep and enjoyment of life). Cronbach alpha coefficients for the pain intensity and interference scales are 0.78-0.96 and 0.83-0.95, respectively.²⁶

Focus group discussions were led using an investigator-developed guide that included rules of conduct and confidentiality. For consistency across all focus groups, the same sequence of discussion topics was used: the menopause experience in general, joint pain symptoms, management strategies, and coping methods during the menopause transition. The same female moderator (N.E.R.) facilitated all focus group discussions with a research assistant (Y.I.C.) who served as an observer and note-taker. The research assistant was a bilingual Latina with extensive experience working with Latino communities in New York City. All focus group sessions were audio recorded and professionally transcribed verbatim. Participants were identified by first name only or an assigned number to maintain anonymity.

The data collection visit lasted approximately 2 hours including the consent process and questionnaires (focus group discussions lasted an estimated 90 minutes). For their participation, participants received a $25 cash payment and a copy of the Menopause Guidebook for Consumers (The North American Menopause Society, 2012). Light refreshments were provided at the group meetings.

Data management and analysis

An emergent content analysis was conducted to identify prominent themes and patterns in the data. Focus group transcripts and audio were entered into NVivo (Qualitative Solutions and Research, Burlington, MA) qualitative software to facilitate the content analysis. Two researchers (Y.I.C. and N.K.R.) independently reviewed transcripts in an iterative process to obtain a sense of the data as a whole.²⁷ Key concepts that related to the four content areas (pain experience, impact on lifestyle, medical management, self-management/coping) were highlighted and organized into smaller codes The researchers discussed each code and labeled them according to the content they represent. Next, the coders met biweekly to define and refine codes until a consensus was reached on a coding scheme. A single coder analyzed the remaining transcripts using the coding scheme. Finally, the codes were organized into themes and quotes identified from the data to exemplify these themes.

Scientific rigor

To enhance study rigor, we focused on the following four criteria established by Lincoln and Guba (1985): credibility, transferability, dependability, and confirmability.²⁸ To address credibility and confirmability, two coders were involved in the data analysis process. In addition, member checks were conducted by verifying information from one focus group with another. To enhance transferability, we collected sociodemographic data before the start of the focus group to provide a detailed description of the research participant’s background for future researchers and clinicians. An audit trail of the research process and findings was maintained to enhance dependability.

Theme #1: Joint pain is an alarming part of the menopause package

This theme refers to participants’ descriptions of the sudden and disturbing emergence of joint pain and stiffness during perimenopause and early postmenopause. Joint pain typically involved more than one area and was described as an unexpected, confusing symptom noted during the menopausal transition. One participant stated: “I went through this, I turned 50 and all of a sudden everything changed. I stopped getting my period; I started getting all these aches in my knees and my wrists and right here [points to knuckles].” This confusion about the sudden emergence of pain and its etiology was further described by another participant:

“I never had any problems. It’s just all of a sudden, menopause, torn meniscus, back problem… arthritis comes with menopause too, doesn’t it? Isn’t it like a package? A third participant added, “the pain is excruciating but I never put the pain and the menopause together. No. I never thought that menopause gives you pain.”

The re-emergence of joint pain and stiffness during perimenopause was also common. Those with existing pain reported it worsening with menopause. One participant described it as follows: “so then it went away [sciatica when she was in her 20s]. Fine. It didn’t bother me at all and I kept dancing and everything. And all of a sudden [age 51], it came back with a vengeance.”

Regardless of onset, joint pain was often viewed as severe and described in vivid terms. Several participants likened their pain experience to being physically attacked: “I feel like they’ve beaten me up—like somebody just came and beat me up.” Another said, “I’ll get like a throbbing in my hands… like somebody is in there… and I’ll say: Hey, get out!… I’m telling it “Get away, get away!”

Theme #2. “I can’t lose my job”—pain disrupts life and livelihood

The distressing impact of pain symptoms on daily activities and quality of life was notable. Most participants reported that pain symptoms interfered substantially with their work, family relationships, and household tasks (eg, cooking, and cleaning). Concerning the workplace, one participant stated, “I am a licensed esthetician and I work standing up…so it’s affecting my livelihood because I can’t stand up.” In another focus group, a participant who was a telemarketer supervisor stated:

“I stand up walking the floor all night, so my knees, I’m popping Ibuprofens all the time. I’ve got bills to pay, I cannot take off from work. The way it is now with jobs, I can’t lose my job.”

Other focus group members described how pain had robbed them of leisure time activities or enjoyable work at home. One woman said,

“Sometimes I’m fine and I feel great and I want to do so many things around my house because I’m in my new apartment. I can’t get to them because the (hip/leg) pain is so excruciating.” Another woman said, “Oh God, going to the movies, it’s my knees…. they end up throbbing and throbbing and throbbing and I can’t take that.”

Later in the same session, this participant disclosed how profound her disability had become: “Sometimes I can’t even sit on the toilet. I literally have to pull my pants down and squat over the toilet like a man…or else I can’t get up. I don’t even try to get in the bathtub.” In another case, pleasant household duties became untenable: “Even my children have noticed. ‘What’s wrong with you? You’re not the same no more.’ I don’t want to cook, and I used to love to cook, especially Sunday.” Another woman revealed how enjoyable duties had been relinquished and reallocated to family members: “I used to turn on the (salsa) music in the house and clean and dance, but it’s not happening… I can’t… my husband and my son does it (housekeeping).”

Theme #3: Unsatisfactory medical care and fear of addiction

Participants sought multiple medical treatments from different sources for their pain including analgesics, steroid injections, physical therapy, and chiropractic treatments. The results have been disappointing: “I did the physical therapy, didn’t do crapola. So, I’m like, ‘Okay, well what’s my other option?’ So now I’m seeing a specialist for the spine and they’re injecting some kind of pain management.” Referrals from primary care providers to rheumatologists and pain specialists were also mentioned as were visits to the emergency room when pain became severe. One participant shared, “they gave me OxyContin and they would shoot me up with Demerol when I’d go in the hospital because I couldn’t move.” Although some participants were prescribed opioids, they were wary of this option. One participant stated, “the pain got so bad my doctor tried to get me on Percocet, but I told him, ‘I can’t, because I’m working and that puts me to sleep.’ So, I told him I can’t mess with that.”

Menopausal hormone/estrogen therapy was also viewed as circumspect, or met with outright rejection, even from two women who had undergone hysterectomy before age 50. Comments such as, “I don’t take any of that. They say that’s not good for you” and “Why do I need that for? I wouldn’t go near it” were common. Women speculated that estrogen therapy was harmful to bones, caused weight gain, and might still be experimental and even addictive. As one participant put it, “I mean, I know that science and medicines (estrogen therapy options) have come a long way, but I also don’t want to get hooked on anything.”

In general, women felt short-changed by their healthcare providers owing to unsatisfactory advice for coping with menopause and joint pain. One participant revealed: “I pop two 800 milligrams each, that’s 1,600 milligrams. And my doctor, he already told me, he don’t give me a prescription for ibuprofen, he said, ‘You need to stop it.’” Another expressed frustration when stating, “So why don’t these doctors give you a paper telling you, ‘Listen, this might happen,’ so that you can know.” A third woman questioned the physician’s approach:

“Why doesn’t he just take care of what the problem is instead of just giving you medication? For the joint pain, there’s nothing.”

A fourth participant remarked: “But he’s not really that helpful (her primary care physician). You know? [Chuckle]. I mean he’ll tell me it’s going to be okay. Tomorrow will be another day.”

Several women described taking the initiative and seeking out care from multiple specialists for a second opinion or when treatments proved ineffective. One participant explained, “Then I said let me go to a physical therapist—someone else, because this orthopedic doctor wasn’t—I mean come on… I took the medicine but then I’m still getting the pain.” Another woman was skeptical when told by an orthopedic specialist that she needed a hip replacement: “and I said, ‘it better be like Alex Rodriguez… I better be able to slide into bases like he does.’ And then I went to a chiropractor.” In another case, a participant speculated: “So maybe I should find another doctor, someone who’s actually going to sit down and listen to me.”

Theme #4. Coping with pain: From maca to marijuana

While participants perceived some medical treatments negatively (eg, opioids), they enthusiastically described self-management strategies including exercise, home remedies, prayer, and in one case, marijuana for their pain. Physical activities such as swimming, salsa dancing, walking, and yoga provided physical and mental relief. For instance:

“…my daughter is in the army and in her housing development they got a gym. Man, and for those two weeks, I was on that treadmill and everything, I felt so much better afterward, I had more energy, I had a better attitude.”

Most women combined exercise with daily chores as opportunities to enhance physical fitness (eg, walking to the grocery store, watching Spanish cable TV exercise shows while housecleaning). One woman added that a $25 gym membership was available at the local YMCA to Medicaid recipients and there were various group exercise classes.

In addition to physical activity, home remedies were popular for pain relief in the form of medicated salves, powders, oils, and teas. One such remedy was maca, “Well I was taking maca, which I have to get some more. It’s a powder. It comes from South America.” Women also used over-the-counter products like Vicks VapoRub at the back of the neck and forehead, Epsom salts in the bath, and lidocaine gel patches for knees and back pain. Other home remedies cited were Woodlock oil, lemon balm tea, and an anesthetic salve purchased in bodegas referred to as “ubre” for sore muscles. Agua de Azahar (orange blossom water) was used to reduce anxiety. One participant revealed that she regularly used cannabis and cannabis-derived products for pain relief:

“I have one (home remedy) and it contains THC and it just works, and it’s fabulous, from the mood to the pain, like I tell you, I don’t pop pills… I go green … I don’t feel no pain, everything keeps moving.”

Participants noted that health providers often overlooked home remedies leaving them to self-manage their pain because there are no other options: “There’s a lot of home remedies, honey, that the doctors don’t have a clue about that work… because according to them, like well, you’re going to be, this is the way you’re going to stay.”

Regardless of home remedy preferences, emotional support from family and friends and/or their religious faith was an important strategy for coping with pain. Sympathetic husbands and friends with similar pain problems were cited as valuable allies: “I have friends, you know, the gatherings. It’s great because it’s like a big party. There’s a celebration there and we have groups like this too, small groups, events where we talk, and we exchange.” Two participants relied on prayer as a coping strategy, with one participant stating, “I pray. I get involved sometimes with praying with a group.” Another said, “I don’t go to church but I’m always praying.”

Finally, stoicism was also implied as a coping strategy when all else failed. One participant summed up that her advice for coping with joint pain and stiffness was to “figure it out for themselves.” Across focus groups, women noted they simply had to “deal with it.”

Limitations and strengths

Our findings should be interpreted in the context of important limitations. This study included English-speaking Latinas from the Washington Heights and Inwood neighborhoods of New York City, who were mainly Puerto Rican and/or were either born or have lived in the continental US for more than 10 years, limiting the transferability of results. Additionally, women varied in age and staging of the menopause transition, which can further limit generalizability. Given the demonstrated influence of elevated BMI on joint pain,⁵ the body weight features of the study cohort may have also played a role in joint pain symptom severity. Findings may differ for Latinas in other geographic settings, first-generation immigrants, or individuals living in the US. for fewer than 10 years. Moreover, we did not assess country of birth or the level of acculturation as a pain modifier, which have been shown to influence reports of other menopause symptoms among Latinas in SWAN.^13,51,52 Additionally, we used a qualitative descriptive approach, which limits interpretation because of its exploratory nature.⁵³ Finally, findings that are nearly a decade old would not in many cases provide useful insights for contemporary practice or future research directions. However, very little has changed in terms of our understanding of cultural influences on menopause symptoms, especially related to joint pain and arthralgias, as evidenced by results from a 2020 global analysis,⁵ a 2021 review of menopause symptoms in US Latinas,⁵⁴ and a 2022 summary of findings from the iconic SWAN study that addressed the paucity of research on the sociocultural and structural factors contributing to the health disparities in menopause symptoms among racially and ethnically minoritized US populations.⁷ At the same time, social media use, which was not assessed in this study, has escalated during the last 10 years, especially after COVID-19, and may have further reinforced both positive and negative cultural influences on menopause symptoms and coping strategies in midlife Latinas such as familismo (loyalty and respect for family values) on the one hand, and distrust and fear of medical personnel on the other.⁵⁵ To what extent an increased use of social media would have altered these findings is unknown, but additional research is needed.

Strengths of this study include its focus on Latinas—an underrepresented group in menopause research. Another strength is the inclusion of a bilingual (English, Spanish) Latina from New York City on the research team, which can enhance trust with participants and better convey the meaning of participants’ experiences. Although the research proposal was reviewed by the Columbia Medical Center’s Community Engagement Advisory Committee composed of researchers, practitioners, and community members, in the future, we recommend that a woman from the community be an active member of the research team.