ABSTRACT
Background:
The age at which menopause occurs varies widely among different populations around the world, and the severity of menopausal symptoms often increases with age. Although menopause is not classified as an illness, it is associated with higher rates of mortality and morbidity among women. Many women go through menopause without adequate knowledge of its health implications. It is essential for women to be informed about the symptoms and complications of menopause so they can manage it effectively and seek appropriate treatment. Without this knowledge and with negative attitudes towards menopause, women may face difficulties during the postmenopausal period.
Objectives:
This study aims to assess the prevalence of menopausal symptoms and to evaluate the knowledge and attitudes of peri- and postmenopausal women toward menopause.
Materials and Methods:
This mixed-method study was conducted at a single center in a major tertiary care hospital located in Chengalpattu, Kanchipuram, Tamil Nadu, from February 2023 to October 2024. A total of 300 women experiencing perimenopausal and menopausal symptoms were included through convenience sampling. Ethical guidelines established by the institutional ethics committee were followed throughout the study. We utilized the Menopause Rating Scale (MRS), a self-reported and validated tool, to assess the severity of menopausal symptoms reported by the participants.
Results:
The most common symptoms reported by perimenopausal women included sleep problems (53.4%), hot flashes (50%), anxiety (67.8%), irritability (65.6%), bladder issues (46.7%), and sexual discomfort (44.4%). In postmenopausal women, frequently reported symptoms were joint pain (56.2%), depressive mood (70%), physical and mental exhaustion (63.4%), vaginal dryness (64.8%), and sexual problems (58.1%). Overall, severe menopausal symptoms were more prevalent among postmenopausal women compared to those in the perimenopausal stage, with a statistically significant difference (P < 0.05). Binomial logistic regression analysis showed that age (adjusted odds ratio [AOR] – 1.78), parity (AOR – 2.49), and poor knowledge about menopause (AOR – 2.78) were significant risk factors associated with the severity of menopausal symptoms.
Conclusion:
This mixed-method study found significant differences in menopausal symptoms, knowledge, and attitudes between peri- and postmenopausal women. In postmenopausal women, higher mean total MRS scores indicated severe somatic, psychological, and urogenital symptoms. We found that menopausal women need tailored education and culturally sensitive support to close knowledge gaps, promote positive attitudes, and meet complex needs.
KEYWORDS: Attitude, knowledge, menopausal symptoms, menopause rating scale, perimenopause, postmenopause
INTRODUCTION
Menopause is a natural and important phase in a woman’s life, marked by the end of fertility and menstruation.[1,2] This natural process leads to the atresia, or gradual loss, of nearly all oocytes in the ovaries.[3] This drop in estrogen can lead to menopausal symptoms such as hot flashes, insomnia, mood swings, and overall physical and mental fatigue.[4,5] Postmenopausal issues may include vaginal atrophy, urinary problems, and an increased risk of osteoporosis, all stemming from physiological changes in women.[6] Hot flushes are particularly prominent, affecting approximately 50%–80% of women during the years surrounding menopause.[7] Although menopause is not classified as an illness, it is associated with increased rates of mortality and morbidity among women.[7]
Generally, menopause typically begins around 50, within an age range of 40–60 years.[8] Previous studies have also indicated that the distribution of menopausal symptoms differs among various ethnicities and racial backgrounds.[9] As life expectancy increases and the average age at menopause remains relatively constant, women spend nearly half of their lives in the postmenopausal phase. Perimenopause is the stage when the body naturally transitions to menopause, marking the end of reproductive years.[10] This phase typically begins in the late 30s and can last until the mid-50s.[7,11] Many women are not well-informed about perimenopause, menopause, and the challenges that accompany them. This lack of awareness is often compounded by social inequalities and discrimination that women face throughout their lives.[12] According to Nuzrat’s report, awareness among women regarding perimenopause and menopause varies due to factors such as age, the number of pregnancies, and socioeconomic status, cultural, educational, and geographical influences.[13]
Menopause is a natural process every woman will experience, but understanding its implications is crucial.[14] Without this knowledge, women may face a problematic postmenopausal period.[14] Generally, higher levels of negative attitudes toward menopause correlate with more severe symptoms.[15] Hence, addressing these gaps in awareness is vital for better health outcomes during this transition.[7] Gebretatyos states that knowledge is essential for accessing health services, while attitude plays a key role in prompting action. A positive attitude can drive health behaviors due to its influence on individuals. Promoting both knowledge and a positive attitude is vital for achieving lasting changes in behavior.[8]
Currently, in our country, the policies and programs focused on promoting women’s health are primarily restricted to specific issues such as pregnancy and family planning, with insufficient attention given to other health needs of women, particularly during the menopausal transition.[1] In India, there is no active national health initiative aimed at addressing the specific health needs of postmenopausal women. Furthermore, very few research studies have been conducted to explore this matter more comprehensively. As a result, this study sought to examine the knowledge and attitudes of peri- and postmenopausal women towards menopause and to evaluate the magnitude of discomfort caused by menopausal symptoms by determining its prevalence using a modified menopause rating scale (MRS) among middle-aged women visiting a tertiary care center in Kanchipuram district of Tamil Nadu.
MATERIALS AND METHODS
Study design and setting
This study used a mixed-method approach with sequential data collection, where qualitative data were collected to support the quantitative results. It was conducted at a single center in one of the major tertiary care hospitals located in Chengalpattu, Kanchipuram, Tamil Nadu, which covers the healthcare requirements of a large portion of the local population. The study was carried out for more than 18 months, from February 2023 to October 2024, and a total of 300 women experiencing perimenopausal and menopausal symptoms who visited the gynecology outpatient department were included in the study through convenience sampling.
Study participants
The study included both postmenopausal and perimenopausal women between 45 and 65 years. Individuals who declined to participate along with women undergoing hormone replacement therapy, were excluded from the study, as it influences the presentation of menopausal symptoms. Furthermore, women with known histories of tumors, tuberculosis, rheumatoid arthritis, or osteoarthritis were excluded. Participants taking antidepressant or antipsychotic medications were also omitted from the study. These selection criteria were established to minimize the effects of specific medical conditions that could cause symptoms similar to or worsen menopausal symptoms. Our aim was to focus on naturally occurring menopausal symptoms and their severity among study participants, thus reducing potential confounding factors.
Sampling and sample size calculation
Based on the available literature, the sample size formula for comparing two proportions was used to calculate the study sample size. With a significance level set at 95%, it was assumed that 57% of perimenopausal women and 84% of postmenopausal women consider hot flushes to be commonly prevalent menopausal symptoms, and factoring in a 5% nonresponse rate, the determined sample size was 180. We utilized a nonrandom sampling method called purposive sampling for the selection of participants.
Operational definition
According to the STRAW + 10 criteria, perimenopausal women were defined as those experiencing irregular menstrual cycles (cycle length variability ≥7 days) or ≥60 days of amenorrhea with associated vasomotor symptoms.[10] Postmenopausal women were defined as individuals who had experienced amenorrhea for 12 consecutive months without alternative pathological or physiological explanations.[10] Where feasible, serum hormonal assays were performed, with perimenopause is characterized by fluctuating estradiol levels and elevated follicle-stimulating hormone (FSH) levels exceeding 25 IU/L, while postmenopause is confirmed by persistently elevated FSH levels above 40 IU/L and low estradiol levels below 30 pg/mL.[10,16]
Study tools and data collection methods
Data were gathered using a pretested questionnaire administered by an interviewer. The first part of the questionnaire contained an informed consent form, and the second part gathered sociodemographic information, such as age, gynecological, and medical history. The third part consists of the MRS, a self-reported, validated tool designed to evaluate the health-related quality of life in menopausal women.
The questionnaire consists of 11 items organized under three distinct domains, each rated on a scale from 0 to 4, where 0 signifies no issues and 4 indicates severe complaints. The scores for each item are aggregated, resulting in a total score that ranges from 0 to 44, where a higher score of 16 indicates severe complaints that require intervention. This scale evaluates the quality of life across three domains: Somatic, psychological, and urogenital. Somatic symptoms include hot flushes, heart discomfort, sleep disturbance, and muscle and joint problems; psychological symptoms encompass depression, irritability, anxiety, and both physical and mental exhaustion, while urogenital symptoms involve sexual dysfunction, bladder problems, and vaginal dryness. Later, a focused group discussion was conducted with voice recordings to collect data on participants’ views regarding menopause. Participants were asked about their feelings towards perimenopause and menopause, along with their opinions on the cessation of menstruation. The recordings were transcribed and categorized, followed by a content analysis that identified several key themes.
Statistical analysis
Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington, USA) and SPSS version 20 (IBM Corp., Armonk, New York, USA) were utilized for data entry and analysis. Categorical variables (sociodemographic variables and the prevalence of menopausal symptoms) were calculated as frequency and percentages, while continuous variables (MRS score) were expressed as means and standard deviations (SDs). An Independent sample t-test was used to determine the potential differences in MRS scores between menopausal and perimenopausal women, while a Z-test was applied to assess the difference in the proportions of knowledge and attitude between the two groups, facilitating a thorough evaluation of the influence of these factors on the severity of menopausal symptoms. A binary logistic regression model was utilized to interpret the relationship between the predictor variables (independent variables) and their outcome variables (severe menopausal complaints), considering potential confounding factors. The adjusted odds ratio (AOR) was computed alongside a 95% confidence interval (CI). A P < 0.05 was deemed statistically significant.
Ethical considerations
This study was conducted according to the ethical guidelines and approved by the Institutional Ethics Committee of SRM Medical College Hospital and Research Center. The study ensured that individuals participated voluntarily, without any coercion and confidentiality was maintained by anonymizing their data using study IDs.
RESULTS
Quantitative data analysis
A total of 300 women between 45 and 65 years who visited the gynecology outpatient department were included. The mean (± SD) age of participants in the study was 49.4 (±4.6) years. The majority of participants were in the age group of 45–50 years (43.7%), followed by 51–55 years (23.7%). Among the study participants, 215 out of 300 (71.7%) were homemakers and 28.3% were employed.
Majority of the participants (86%) were multiparous and 70% of the study participants had attained menopause. The mean age (±SD) of menopause for the postmenopausal women was 48.7 (±3.2) years, and majority among them (79.5%) attained menopause between 45 and 50 years. The mean (±SD) duration of menopause among menopausal women was 4.8 ± 3.6 years with majority of the menopausal women (61.4%) had attained menopause within 5 years. Nearly 50% of women had normal body mass index (BMI); however, 28.4% were obese, and the mean BMI (±SD) was 29.5 (±4.0) kg/m2. Majority (76%) of the participants were not engaged in any physical activity apart from their routine daily activities [Table 1].
Table 1.
Sociodemographic, obstetric, and medical characteristics of the study participants (n=300)
| Characteristics | n=300, n (%) |
|---|---|
| Age in groups (years) | |
| 45–50 | 131 (43.7) |
| 51–55 | 71 (23.7) |
| 56–60 | 91 (30.3) |
| >60 | 7 (2.3) |
| Age (years), mean±SD | 49.4±4.6 |
| Occupation | |
| Homemaker | 215 (71.7) |
| Employed | 85 (28.3) |
| Parity | |
| Primiparous | 38 (12.7) |
| Multiparous | 258 (86.0) |
| Grand multiparous | 4 (1.3) |
| Comorbidities | |
| Yes | 198 (66.0) |
| No | 102 (34.0) |
| Menstrual status | |
| Perimenopausal | 90 (30.0) |
| Menopausal | 210 (70.0) |
| Age at menopause (years) | |
| <45 | 2 (0.9) |
| 45–50 | 167 (79.5) |
| 51–55 | 41 (19.6) |
| Age at menopause (years), mean±SD | 48.7±3.2 |
| Duration of menopause (years) | |
| <5 | 129 (61.4) |
| 5–10 | 70 (33.3) |
| 11–15 | 11 (5.3) |
| Duration of menopause (mean±SD) | 4.8±3.6 |
| BMI classification (kg/m2) | |
| Normal: 18.6–24.9 | 30 (10.0) |
| Overweight: 25.0–29.9 | 151 (50.3) |
| Obese: 30.0–34.9 | 85 (28.4) |
| Morbidly obese: >35.0 | 34 (11.3) |
| BMI (kg/m2), mean±SD | 29.5±4.0 |
| Physical activity | |
| Yes | 72 (24.0) |
| No | 228 (76.0) |
BMI: Body mass index, SD: Standard deviation
Among perimenopausal women, the most prevalent somatic symptoms were sleep problems (54.5%), muscle and joint problems (53.3%), and hot flushes (51.1%). Similarly, postmenopausal women also commonly experienced muscle and joint problems (86.6%), sleep problems (81.0%), and hot flushes (70.5%). When comparing these two groups, postmenopausal women reported a higher incidence of somatic symptoms, including sleep problems, muscle and joint issues, hot flushes, and heart discomfort, and the differences were statistically significant (P < 0.05*) [Table 2].
Table 2.
Frequency distribution of menopausal symptoms among study population (n=300)
| Menopausal symptoms (based on MRS) | Perimenopausal women (n=90), n (%) | Postmenopausal women (n=210), n (%) | P |
|---|---|---|---|
| Somatic complaints | |||
| Hot flushes | 46 (51.1) | 148 (70.5) | 0.01* |
| Heart discomfort | 23 (25.6) | 107 (51.1) | 0.01* |
| Sleep problems | 49 (54.5) | 170 (81.0) | 0.01* |
| Muscle and joint problems | 48 (53.3) | 182 (86.6) | 0.01* |
| Psychological complaints | |||
| Depressive mood | 53 (58.9) | 170 (81.0) | 0.01* |
| Irritability | 60 (66.7) | 160 (76.2) | 0.10 |
| Anxiety | 63 (70.0) | 154 (73.3) | 0.59 |
| Physical and sexual exhaustion | 53 (58.9) | 167 (79.5) | 0.01* |
| Urogenital complaints | |||
| Sexual problems | 40 (44.4) | 134 (63.8) | 0.01* |
| Bladder problems | 56 (62.2) | 146 (69.5) | 0.17 |
| Dryness of vagina | 36 (40.0) | 149 (71.0) | 0.01* |
MRS: Menopause Rating Scale
Majority of perimenopausal women reported anxiety (70.0%) and irritability (66.7%). Regarding urogenital symptoms, most perimenopausal women reported bladder problems (62.2%) and sexual discomfort (44.4%). For postmenopausal women, the most commonly reported psychological symptoms included a depressive mood (81%) and physical and mental exhaustion (79.5%). Common urogenital symptoms among this group included vaginal dryness (71.0%) and sexual issues (63. 8%). Postmenopausal women reported a higher proportion of psychological and urogenital symptoms compared to perimenopausal women. Statistically significant differences (P < 0.05*) were found in depressive mood (P = 0.04), physical and mental exhaustion (P = 0.01), sexual problems (P = 0.03), and vaginal dryness (P = 0.01). Overall, menopausal symptoms were more prevalent in postmenopausal women compared to perimenopausal women.
The mean total MRS score was 13.71 ± 7.37 for postmenopausal women and 8.95 ± 7.02 for perimenopausal women, respectively. In postmenopausal women, the mean scores for the somatic, psychological, and urogenital domains were 5.12 ± 2.77, 5.46 ± 3.68, and 3.19 ± 2.06, respectively. The scores for somatic, psychological, and urogenital complaints were significantly higher in postmenopausal women compared to perimenopausal women [Table 3].
Table 3.
Menopause Rating Scale score in each domain and overall score of menopause symptoms among perimenopausal and postmenopausal women
| MRS score | Perimenopausal women (n=90), mean±SD | Postmenopausal women (n=210), mean±SD | P |
|---|---|---|---|
| Somatic complaints | 2.86±2.72 | 5.12±2.77 | 0.01* |
| Psychological complaints | 3.86±3.12 | 5.46±3.68 | 0.01* |
| Urogenital complaints | 2.15±2.02 | 3.19±2.06 | 0.01* |
| Overall score | 8.95±7.02 | 13.71±7.37 | 0.01* |
SD: Standard deviation, MRS: Menopause Rating Scale
More than half of the participants (>50%) had good knowledge regarding menopause. Most perimenopausal women (91.1%) and postmenopausal women (82.9%) were aware of the age range at which women typically reach menopause. However, compared to perimenopausal women, postmenopausal women displayed poorer knowledge in several areas, including the onset of menopause (28.6%), menstrual irregularities that can occur before menopause (9.0%), awareness of cardiovascular risk factors (17.1%) and metabolic risks (19%), as well as understanding that menopause is a normal part of the aging process (11.9%). There were statistically significant differences in menopause knowledge between perimenopausal and postmenopausal women, with the latter group showing poorer knowledge overall. Compared to the postmenopausal group, the perimenopausal group exhibited a better attitude toward menopause and its associated symptoms. The majority of women in both the perimenopausal (83.3%) and postmenopausal (86.7%) groups agreed that they require a medical evaluation after their final menstrual period. Few women in the postmenopausal group felt that menopause was a period of loneliness (21%). They also reported a loss of interest in their husbands (24.8%) and felt that menopause diminished their appearance (22.9%). The differences in attitudes between the two groups were statistically significant (P < 0.05*) [Table 4].
Table 4.
Frequency distribution of participant knowledge and attitude regarding menopause and its symptoms
| Characteristics | Perimenopausal (n=90), n (%) | Postmenopausal (n=210), n (%) | P |
|---|---|---|---|
| Poor knowledge | |||
| At the time of menopause, menopause stops suddenly? | 6 (6.7) | 60 (28.6) | 0.01* |
| All women attain menopause between 48 and 55 years of age? | 8 (8.9) | 36 (17.1) | 0.07 |
| Majority of women experience menstrual irregularities before menopause? | 2 (2.2) | 19 (9.0) | 0.02* |
| Does menopause lead to obesity and weight gain? | 9 (10.0) | 40 (19.0) | 0.05* |
| Does menopause lead to bone loss? | 12 (13.3) | 37 (17.6) | 0.28 |
| Can regular physical activity prevent bone loss? | 20 (22.2) | 72 (34.3) | 0.04* |
| Can menopause lead to increased risk for heart disease? | 26 (28.9) | 36 (17.1) | 0.02* |
| Can menopause affect the concentration and memory power of women? | 11 (12.2) | 35 (16.7) | 0.27 |
| Are you aware about hormone replacement therapy? | 34 (37.8) | 69 (32.9) | 0.40 |
| Menopause is due to normal aging process | 4 (4.4) | 25 (11.9) | 0.03* |
| Are sexual activities possible postmenopause? | 8 (8.9) | 31 (14.8) | 0.15 |
| Poor attitude | |||
| Do women require medical evaluation after amenorrhea? | 15 (16.7) | 28 (13.3) | 0.36 |
| Does menopause add to woman’s freedom? | 42 (46.7) | 100 (47.6) | 0.87 |
| Do you believe that women have more value in the society postmenopause? | 68 (75.6) | 58 (75.2) | 0.85 |
| Do women lose womanhood postmenopause? | 12 (13.3) | 38 (18.1) | 0.28 |
| Do you think menopause is the period of woman’s loneliness? | 7 (7.8) | 44 (21.0) | 0.01* |
| Menopause is the period of eradicating the problems of menstruation, how do you feel about it? | 18 (20.0) | 42 (19.1) | 0.84 |
| Do you feel that in menopause period, interest and attention of woman towards her husband decreases? | 10 (11.1) | 52 (24.8) | 0.02* |
| Menopause decreases the grace of woman’s appearance? | 7 (7.8) | 48 (22.9) | 0.01* |
| Menopause is the beginning of another life and second maturity of woman | 46 (51.1) | 98 (46.7) | 0.52 |
The logistic model analysis was done to identify independent predictors of severe menopausal symptoms, as measured by the MRS, in both groups while controlling for potential confounders. The results indicated that age, parity, and poor knowledge about menopause were significant risk factors associated with the severity of menopausal symptoms. Women aged <50 years showed more severe symptoms (AOR – 1.78, 95% CI: 1.00–3.14, P = 0.05) compared to those over 50. In addition, primiparous women were found to be at a higher risk of experiencing severe symptoms (AOR – 2.49, 95% CI: 1.01–6.09, P = 0.05) than multiparous women. Furthermore, a lack of knowledge regarding menopause and its related symptoms increases the risk of perceiving severe symptoms (AOR – 2.78, 95% CI: 1.12–6.92, P = 0.03), which was also statistically significant. Regression analysis revealed no statistical associations with other factors, such as menopausal age, duration of menopause, physical activity, BMI, and attitudes toward menopause [Table 5].
Table 5.
Independent predictors of severe menopausal symptoms
| Independent predictors of perceiving severe symptoms | AOR | 95% CI | P |
|---|---|---|---|
| Age (years) | |||
| ≤50 | 1.78 | 1.00–3.14 | 0.05* |
| >50 | References | ||
| Parity | |||
| Primiparous | 2.49 | 1.01–6.09 | 0.05* |
| Multiparous | References | ||
| Age at menopause (years) | |||
| ≤45 | 0.97 | 0.86–1.09 | 0.64 |
| >45 | References | ||
| Duration of menopause (years) | |||
| ≤5 | 0.91 | 0.79–1.04 | 0.17 |
| >5 | References | ||
| Physical activity | |||
| Yes | References | ||
| No | 1.25 | 0.62–2.49 | 0.53 |
| BMI (kg/m2) | |||
| ≥30 | 1.02 | 0.95–1.09 | 0.52 |
| <30 | References | ||
| Poor knowledge | |||
| Yes | 2.78 | 1.12–6.92 | 0.03* |
| No | References | ||
| Poor attitude | |||
| Yes | 1.78 | 0.52–6.09 | 0.35 |
| No | References |
BMI: Body mass index, CI: Confidence interval, AOR: Adjusted odds ratio
Qualitative data analysis
In total, 300 participants shared their feelings in their own words. The analysis revealed themes such as relief and liberation, positive acceptance of this life phase, challenges and mixed emotions, anticipation, and transition, and the importance of the support system. Furthermore, it included cultural perspectives and suggested possible health interventions.
Relief and freedom
A key theme is the relief after the end of menstrual cycles, with women emphasizing the greater freedom to travel, attend family events, and organize their schedules without period concerns.
“Feeling relieved, no more periods.”
“Can travel anytime, attend family functions without worry.”
Positive acceptance as a life phase
Many women perceive menopause as a natural milestone associated with their changing roles within the family and society. This viewpoint might stem from cultural teachings that normalize menopause and frame it as a phase of wisdom or liberation. In various cultures, menopause signifies a transition to elder status, which can lead to increased respect or new responsibilities.
“Part of a woman’s life. Needs family support and understanding.”
“Feeling comfortable.”
Challenges and mixed emotions
Despite the positive aspects, many women reported struggles with physical and emotional symptoms, including hot flashes, joint pain, sleep disturbances, mood swings, irritability, and feelings of aging.
“Not having periods anymore is great, but the symptoms can be exhausting.”
“Freedom from periods is good, but menopause comes with its own set of difficulties.”
Anticipation and transition
Women going through the perimenopausal phase conveyed a sense of eagerness regarding the transition, frequently showing a combination of relief and apprehension. These reactions suggest a need for active preparation and education during this stage.
“Waiting for periods to end.”
“Looking forward to the freedom of no longer planning around menstruation.”
Role of support systems
Women often emphasized the need for family support to cope with the transitions associated with menopause. The emotional backing from spouses, children, or other family members can significantly influence a woman’s experience of menopause.
“Part of a woman’s life. Needs family support and understanding.”
“With support, it feels easier to cope with menopause.”
DISCUSSION
In this prospective observational study, 300 women aged between 45 and 65 were recruited, with a mean age (± SD) of 49.4 (±4.6) years. Most participants were in the 45 and 50 years age group (43.7%), and 71.7% were homemakers. In an Egyptian study assessing knowledge and attitudes toward menopause included women aged 40–60 years and the mean age of the participants was 47.7 ± 3.1 years, with the majority (89%) being over the age of 45 years.[17] Few other studies conducted with similar aims, also recorded that the mean age of participants was 49 years, and most of the participants (41.8%) were in the 46–50 age range.[18,19]
Among the participants, 30% (90 women) were in the perimenopausal stage, and 70% (210 women) were in the postmenopausal stage. In addition, 66% had some comorbidities. The mean age (± SD) at menopause for the postmenopausal women was 48.7 (±3.2) years. Our study showed that 28.4% of the participants fall into the obese category, and 76.0% reported not participating in physical activity. In a short-term study conducted in Tamil Nadu involving 350 women, most participants were housewives (53%), with over half (54%) reporting no physical activity.[20] When assessing obesity, it was identified that 25.4% had a BMI >30 kg/m2 (obese I category), and 70.1% were found to have various comorbidities such as hypertension and diabetes, which was consistent with our results.[20]
While assessing the menopausal symptoms in perimenopausal and postmenopausal women using the MRS, postmenopausal women reported a higher incidence of somatic symptoms, such as sleep problems, muscle and joint issues, hot flushes, and heart discomfort (P < 0.01). They also experienced more psychological and urogenital symptoms, showing significant differences in depressive mood (P = 0.01), exhaustion (P = 0.01), sexual problems (P = 0.01), and vaginal dryness (P = 0.01).
In a Malaysian study using a MRS by Rahman et al.[21] identified joint and muscular pain (80.1%), physical and mental exhaustion (67.1%), and sleep problems (52.2%) as the most common symptoms in middle-aged women.[21] Other symptoms included anxiety, depressive moods, hot flushes, irritability, and vaginal dryness. Contrary to our findings, their study indicated that perimenopausal women experienced a higher proportion of somatic and psychological symptoms compared to postmenopausal women.[21] However, urogenital symptoms were predominantly found in the postmenopausal group, with the differences probably arising from variations in the study settings.[21] Sundararajan and Srinivasan found that 73.9% of postmenopausal women experienced joint and muscular pain, followed by sleep problems (70.2%) and exhaustion (63.4%).[22] Sexual problems showed the lowest prevalence, supporting our results probably due to underreporting due to social stigma and misconceptions. Perera and Goonewardena reported that menopausal symptoms such as joint and muscular pain, sleep problems, physical and mental exhaustion, depressive moods, irritability, hot flushes, anxiety, and heart discomfort were more common in postmenopausal women compared to those in the perimenopausal stage, with statistically significant differences (P < 0.05), which aligns with our findings.[23] The mean total MRS score was 13.71 ± 7.37 for postmenopausal women and 8.95 ± 7.02 for perimenopausal women, respectively. Our analysis also indicated that scores for somatic, psychological, and urogenital complaints were significantly higher in postmenopausal women compared to perimenopausal women. AlQuaiz et al. conducted a study on the symptoms of menopause and their severity in Saudi women. They reported that the mean total MRS score for postmenopausal women was 13.34 ± 6.90.[24] Moreover, the study revealed that somatic symptoms were more prevalent among perimenopausal women compared to postmenopausal women.[24] In this study, postmenopausal women reported more severe menopausal symptoms than perimenopausal women, as measured by the MRS.
This increased severity in postmenopausal women is likely due to the prolonged decline in estrogen levels after menopause. During perimenopause, fluctuating estrogen levels from irregular ovarian function may provide some relief from symptoms. In contrast, the complete halt of ovarian function in postmenopausal leads to a significant decrease in estrogen, exacerbating symptoms like hot flashes, sleep disturbances, and joint pain. In addition, the long-term lack of estrogen can worsen urogenital atrophy and musculoskeletal pain, contributing to higher MRS scores. Psychological stress related to aging may also heighten awareness of menopausal symptoms in postmenopausal women.
More than half of the participants displayed a good knowledge of menopause. The majority of perimenopausal women (91.1%) and postmenopausal women (82.9%) were aware of the typical age range at which women reach menopause. However, postmenopausal women demonstrated poorer knowledge compared to their perimenopausal women. Statistically significant differences were noted in several knowledge aspects, including the onset of menopause (28.6%), menstrual irregularities that can occur before menopause (9.0%), awareness of cardiovascular risk factors (17.1%), metabolic risks (19%), and the understanding that menopause is a normal part of the ageing process (11.9%). Khokhar in their study that 80% of women had prior knowledge of menopause, and 71.8% viewed menopause as a regular event.[13] Similarly, Perera and Goonewardena also observed that half (50%) of the participants had good knowledge of menopause.[23] The study of menopause as a natural part of the aging process supports our findings.[23] The results emphasize the stage-specific nature of health awareness, highlighting opportunities for targeted education. Women in the perimenopausal phase are more likely to seek information about menopause as they directly experience menstrual irregularities and other transitional symptoms. In contrast, postmenopausal women may feel less urgency to learn about menopause and its health risks as they move past these acute changes and attribute it to aging.[1] Psychosocial factors, including stigma and cultural beliefs, can also hinder seeking this information, as menopause remains a taboo topic in some cultures, particularly among older generations.[1] In the present era, probably social media has helped perimenopausal women to have better knowledge than postmenopausal women. This implies other ways to target postmenopausal women and perimenopausal women to improve their knowledge should be implemented.
Both perimenopausal and postmenopausal women generally shared similar attitudes toward menopause. However, there were a few areas where the perimenopausal group displayed a more positive and empowered attitude than the postmenopausal women, such as feeling that menopause was a period of loneliness (21%), a loss of interest in their husbands (24.8%), and a belief that menopause diminished their appearance (22.9%) demonstrating statistically significant differences. Tariq et al. also observed significant differences in women’s attitudes toward menopause in a few areas based on their menopausal status, although overall, the attitudes of the perimenopausal and postmenopausal groups were quite similar.[15] In addition, Kwak et al. reported no statistically significant difference in menopause knowledge or overall attitudes toward menopause based on the menopause stage.[8] Our study’s findings emphasize the need for targeted interventions to improve menopausal knowledge and attitudes, especially among postmenopausal women with knowledge gaps and negative attitudes. This includes government reproductive health policies that prioritize menopausal education. In addition, primary health centers deliver community-based awareness programs with trained healthcare professionals to dispel myths and promote positivity.
This study observed that age, parity, and poor knowledge about menopause were significant risk factors associated with the severity of menopausal symptoms, but the regression analysis did not reveal any statistical associations between severe menopausal symptoms and other factors, such as menopausal age, duration of menopause, physical activity, BMI, and attitudes toward menopause. Wang et al. observed in their study that menopausal status, nulliparity, and chronic diseases are associated with a higher risk of experiencing severe menopausal symptoms.[25] Few more studies conducted in China also found that older age, a higher BMI, and being in peri- or postmenopausal status are at increased odds of having a higher menopausal symptom score and cause delays in seeking healthcare services.[26,27]
CONCLUSION
This mixed-method study found significant differences in menopausal symptoms, knowledge, and attitudes between peri- and postmenopausal women. Women with postmenopause had higher mean total MRS scores, indicating more severe somatic, psychological, and urogenital symptoms. While more than half of the participants had adequate knowledge of menopause, postmenopausal women had significant knowledge gaps, particularly regarding the onset, health risks, and normal aging. Attitudinal differences were also evident, with perimenopausal women displaying a more positive outlook towards menopause. Despite these differences, both groups agreed that postmenopause medical evaluation is important. Qualitative findings showed emotional responses ranging from relief and acceptance to challenges shaped by cultural beliefs and the need for strong support systems. Our findings underscore the need for tailored educational interventions and culturally sensitive support strategies to close knowledge gaps, foster positive attitudes, and meet the complex needs of menopausal women. Our research suggests that governmental bodies launch health-menopausal clinics and education programs centered around menopause and its related symptoms to improve women’s health and dispel misconceptions.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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