ABSTRACT
Background:
Menopause and its effects on lifestyle of a woman has now become an important emerging public health issue owing to the global rise in life expectancy. Menopause is not a disease but the symptoms and their severities, can be very challenging and remain largely ignored by the policy makers and physicians.
Objectives:
The aim of the present study was to find out the factors influencing the severity of menopausal symptoms among post-menopausal females.
Materials and Methods:
A cross-sectional study conducted for a period of one year. Data collected using systematic random sampling from 255 post-menopausal women and analysis was performed with Epi-Info 7.2. Chi-square applied as statistical test of significance for the association between severity of menopausal symptoms and qualitative variables. P < 0.05 considered to be statistically significant.
Results:
The mean age of the study participants was found to be 53.86 ± 7.15 years. The present study concludes that residing locality, educational status, occupation, certain lifestyle factors and some socio-cultural factors, type of menopause and duration since menopause was found to be statistically significantly related to severity of menopausal symptoms.
Conclusion:
Large efforts are required to make women aware of menopausal symptoms so that they can seek treatment, if necessary.
Keywords: Cross-sectional study, post-menopausal females, severity of menopausal symptoms
Introduction
The word “menopause” has Greek origin: “Meno” means month and “pause” means to end.[1] Menopause is a critical event in the life of a woman marked by the cessation of her menstrual cycles.[2] It is a normal physiological event defined as consecutive amenorrhea at least for 12 months and the leading cause for which is declining ovarian function that happens invariably to all women in their midlife.[3,4] Menopause is a signal of the end of reproductive phase of a woman’s life where the ovaries gradually cease to function passing through the phase known as menopausal transition or perimenopause.[1] Ovarian function depletion causes a variety of somatic, sexual, vasomotor, and psychological manifestations that leads to an impairment of the quality of life of women.[4,5,6] Menopause can also be surgically induced by hysterectomy with or without oophorectomy, referred to as surgical menopause. Likewise, it can also occur due to treatment with cytotoxic chemotherapeutic agents and the gonadotrophic-releasing hormone agonist.[7]
The global life expectancy is on rise due to the provision of better nutrition and improved health-care delivery,[8] leading to a rise in the geriatric population including postmenopausal females thereby making “menopause” a predominant study topic. The global population of postmenopausal women in 1990 was approximately 476 million. It is estimated that this figure will reach around 1200 million mark by 2030 with 76% of postmenopausal women residing in the third world countries.[9] According to the World Health Statistics 2021, globally, the female life expectancy at birth is 79.1 years while that in developed countries such as the USA and Great Britain is 79.3 years and 80.9 years, respectively.[10] The average life expectancy at birth for females in India is 70.47 years.[10] The average age at natural menopause ranges from 45 to 53 years both in the developed and developing countries,[11,12,13,14,15] which implies that women now live approximately more than one-third of their life after ovarian depletion.
The influence of menopause can be seen remarkably in various dimensions of health such as physical, psychological, and socio-cultural.[16] As the average length of life after menopause is globally on an increase, thus it becomes the responsibility of health-care delivery system including primary care physicians and family physicians to pay a greater attention towards the health issues of postmenopausal women, enabling them to relish the so-called “gloomy” years of life in their full capacity.
The menopausal symptoms are multiple and differ from one study to the other. For some women, the menopausal symptoms may be severe and pose a challenge to their routine activities, while for others, they may be mild and the transition is accepted smoothly.[14] It is understood that these symptoms may be influenced by a combination of physical changes, cultural influences and individual perceptions and expectations.[15] Menopause is not a disease but the symptoms and their severities, which are mainly subjective, can be very challenging. In India, however this mid-phase of life between reproductive age and geriatric age group, is generally ignored by the policy makers and the women chooses to mourn silently. Hence, the current study tends to make a humble attempt to draw the attention of primary care and family physicians along with policy makers towards the unaddressed needs of these middle aged women so that their quality of care can be improved enabling them to spend those twilight years of their life happily.
Aims and objectives
The aim of the present study was to find out the factors influencing severity of menopausal symptoms among post-menopausal females.
Settings and design
A cross-sectional study was carried out among postmenopausal females attending OPD of Obstetrics and Gynecology at Sultania Zanana Hospital, Bhopal, Madhya Pradesh.
Materials and Methods
This cross-sectional study was carried out over a period of one year starting from 01 July 2015 to 30 June 2016, among postmenopausal females attending the gynecology OPD of Obstetrics and Gynecology at Sultania Zanana Hospital, Bhopal, Madhya Pradesh which is the teaching Hospital of Gandhi Medical College, Bhopal, Madhya Pradesh. Those females who had amenorrhea continuously at least past 12 months and those females who had attained menopause surgically by means of total abdominal hysterectomy with bilateral salpingo-oophorectomy or had documented exposure to cytotoxic chemotherapeutic agents at least 6 months back and willing to participate in the study were included. Exclusion criteria included females already undergoing treatment for hypo estrogenic states and those who were severely ill. Ethical clearance was taken from the ethical committee of the institution.
The sample size for the present study was calculated on the basis of data collected from a pilot study which was conducted for one month. Sample size was calculated on the basis of the following formula:
Here Z1-α/2 = is standard normal variate (at 5% type I error [P < 0.05] it is 1.96 and at 1% type error [P < 0.001] it is 2.58). As in majority of studies P values are considered significant below 0.05 hence 1.96 is used in formula.
P = Expected proportion in population based on previous studies or pilot study.
d = Absolute error or precision: it has to be decided by researcher.
Precision chosen by me is 0.05.
DEFF = Design effect. It is calculated as: Cluster variance/SRS variance.
The proportion of the least reported menopausal symptom, i.e. anxiety (inner restlessness and feeling panicky), in the pilot study was 0.08%. Hence, the sample size without DEFF was:
Design effect (DEFF) was calculated to be 2.24.
Thus, total sample size is 113 × 2.24 = 253.12.
We took 255 cases.
The sample included women experiencing natural menopause as well as those in whom menopause was surgically induced. Data were collected using systematic random sampling technique. Three alternating days in a week was decided to collect data. In first and third week of every month Monday, Wednesday and Friday were chosen for data collection and in the second and fourth week Tuesday, Thursday and Saturday were chosen.
After obtaining consent from the study participants and ensuring confidentiality of the data provided by them, data were collected by face-to-face interview of the participants using semi structured questionnaire that included socio-demographic variables like age, education, occupation, monthly income of family, type of family, number of family members, marital status and variables like height (in cm), weight (in kg). It also included variables related to personal history like addiction, diet, exercise, life style, etc., Detailed Obstetric and Gynecological history was taken along with past medical and surgical history. Menopausal symptoms and their severity were assessed by using menopause rating scale (MRS).[15] Women with total MRS score ≤17 were considered to have mild to moderate symptoms, while those having score >17 were taken to be having severe symptoms.
Data were entered into MS excel 2007 and analysis done with the help of Epi -Info 7.2 software, Developer- CDC, Atlanta, Georgia, USA. Frequency and percentages were calculated. Chi-square was applied as statistical test of significance for association between severity of menopausal symptoms and qualitative variables. P < 0.05 was considered to be statistically significant.
Results
In the present study, the mean age of the study participants was found to be 53.86 ± 7.15 years. Analysis of the data determined a mean age of 46.77 ± 3.52 (standard deviation [SD]) years at natural menopause. Figure 1 shows distribution of study participants according to relation between severity of menopausal symptoms and socio-demographic factors. With regard to residing locality, 87.76% females residing in urban locality experienced severe menopausal symptoms as compared to 74.07% females residing in rural areas and the difference was statistically significant (P = 0.005). Regarding educational status, 71.62% literate females experienced severe menopausal symptoms and the difference was found statistically significant (P = 0.006). With regard to occupation/working status, 87.32% Housewives experienced more severe menopausal symptoms as compared to 75.22% working females and this was found to be statistically significant (P = 0.012). 83.40% of those females who lived with family experienced more severe symptoms which were found to be statistically significant (P = 0.013). Marital status and socio-economic status did not show statistically significant association with severity of menopausal symptoms.
Figure 1.
Distribution of study participants according to relation between severity of menopausal symptoms and socio-demographic factors
Figure 2 shows distribution of study participants according to relation between severity of menopausal symptoms and lifestyle factors. With regard to exercise, 84.21% of females who were not engaged in any kind of exercise experienced severe menopausal symptoms as compared to 71.74% of those females who did regular exercise and the difference was found to be statistically significant (P = 0.04). Regarding H/O tobacco addiction, out of the total females who gave a history of tobacco addiction, 89.22% experienced severe menopausal symptoms as compared to only 77.12% who denied consuming tobacco and the difference was found statistically significant (P = 0.013). Dietary habits did not show statistically significant association with severity of menopausal symptoms. Tea/coffee intake, weekly fasting and body mass index (BMI) did not show statistically significant association with severity of menopausal symptoms.
Figure 2.
Distribution of study participants according to relation between severity of menopausal symptoms and lifestyle factors
Table 1 shows distribution of study participants according to relation between severity of menopausal symptoms and socio-environmental factors. With regard to diurnal variation in symptom severity, 89.82% of females who reported positive diurnal variation experienced severe menopausal symptoms as compared to 67.05% of those females who did not report diurnal variation of symptom severity and the difference was found to be statistically significant (P < 0.05) suggesting that menopausal symptoms might be more severe during a particular time of the day, as in this study majority reported symptoms to be more severe during night. Regarding exposure to noise, out of the total females who gave a history of exposure to noise pollution, 89.28% experienced severe menopausal symptoms as compared to 76.22% who denied exposure to noise and the difference was found statistically significant (P < 0.05). With regard to untoward life incidence, 90.00% of females who went through difficult life situations such as death of near and dear ones or physical trauma like accidents or sexual abuse, experienced severe menopausal symptoms as compared to 78.28% of those females who denied such life incidences and this difference was found to be statistically significant (P < 0.05). Seasonal variation of symptoms, variation of symptoms with bright light, dirty surroundings and unsolved relationships/familial problems did not show statistically significant association with severity of menopausal symptoms.
Table 1.
Distribution of study participants according to relation between severity of menopausal symptoms and socio-environmental factors
| Socio-environmental factors | Group | Severity of menopausal symptoms based on total MRS score, n (%) | Total, n (%) | Significance | |
|---|---|---|---|---|---|
|
| |||||
| Mild to moderate (score ≤17) (n=46) | Severe symptoms (score >17) (n=209) | ||||
| Seasonal variation of symptoms | Yes | 12 (14.29) | 72 (85.71) | 84 (100.00) | χ2=1.1936; df=1; P=0.274 |
| No | 34 (19.88) | 137 (80.12) | 171 (100.00) | ||
| Diurnal variation of symptoms | Yes | 17 (10.18) | 150 (89.82) | 167 (100.00) | χ2=20.218; df=1; P=0.0001* |
| No | 29 (32.95) | 59 (67.05) | 88 (100.00) | ||
| Variation of symptoms with bright light | Yes | 10 (20.00) | 40 (80.00) | 50 (100.00) | χ2=0.1617; df=1; P=0.687 |
| No | 36 (17.56) | 169 (82.44) | 205 (100.00) | ||
| Variation of symptoms with noise | Yes | 12 (10.72) | 100 (89.28) | 112 (100.00) | χ2=7.248; df=1; P=0.007* |
| No | 34 (23.78) | 109 (76.22) | 143 (100.00) | ||
| Dirty surroundings affecting symptom severity | Yes | 6 (27.27) | 16 (72.73) | 22 (100.00) | χ2=1.252; df=1; P=0.263 |
| No | 41 (17.60) | 192 (82.40) | 233 (100.00) | ||
| Unsolved relationship/familial problem | Yes | 4 (19.05) | 17 (80.95) | 21 (100.00) | χ2=0.016; df=1; P=0.9002 |
| No | 42 (17.95) | 192 (82.05) | 234 (100.00) | ||
| Any untoward life incidence | Yes | 8 (10.00) | 72 (90.00) | 80 (100.00) | χ2=5.096; df=1; P=0.02* |
| No | 38 (21.72) | 137 (78.28) | 175 (100.00) | ||
*Statistically significant. MRS=Menopause rating scale
Table 2 shows distribution of study participants according to relation between severity of menopausal symptoms and menstrual/reproductive factors. With regard to type of menopause, 60.87% of females who attained menopause surgically, experienced severe menopausal symptoms as and this difference was found to be statistically significant (P < 0.05) suggesting that surgically induced menopause might result in more severe menopausal symptoms. With regard to duration since menopause, 78.31% females whose last menstrual period was within 10 years experienced more severe menopausal symptoms than those who had elapsed >10 years since last menstrual period and the difference was statistically significant (P < 0.05). History of oral contraceptive use, history of abortions, age at last delivery and parity did not show statistically significant association with severity of menopausal symptoms.
Table 2.
Distribution of study participants according to relation between severity of menopausal symptoms and menstrual/reproductive factors
| Menstrual/reproductive factors | Group | Severity of menopausal symptoms based on total MRS score, n (%) | Total, n (%) | Significance | |
|---|---|---|---|---|---|
|
| |||||
| Mild to moderate (score ≤17) (n=46) | Severe symptoms (score >17) (n=209) | ||||
| Type of menopause | Natural | 37 (15.95) | 195 (84.05) | 232 (100.00) | χ2=7.606; df=1; P=0.005* |
| Surgical | 9 (39.13) | 14 (60.876) | 23 (100.00) | ||
| Duration since menopause | Up to 10 years | 41 (21.69) | 148 (78.31) | 189 (100.00) | χ2=6.594; df=1; P=0.01* |
| >10 years | 5 (7.58) | 61 (92.42) | 66 (100.00) | ||
| History of oral contraceptive use | Yes | 4 (28.57) | 10 (71.43) | 14 (100.00) | χ2=1.112; df=1; P=0.292 |
| No | 42 (17.43) | 199 (82.57) | 241 (100.00) | ||
| History of abortions | Yes | 8 (13.79) | 50 (86.21) | 58 (100.00) | χ2=0.916; df=1; P=0.339 |
| No | 38 (19.29) | 159 (80.71) | 197 (100.00) | ||
| Age at last delivery (n=250) | Up to 30 years | 24 (23.53) | 78 (76.47) | 102 (100.00) | χ2=3.019; df=1; P=0.082 |
| >30 years | 22 (14.86) | 126 (85.14) | 148 (100.00) | ||
| Parity | Up to 2 | 9 (31.04) | 20 (68.96) | 29 (100.00) | χ2=3.893; df=2; P=0.1427 |
| 3–5 | 19 (15.45) | 104 (84.55) | 123 (100.00) | ||
| >5 | 18 (17.48) | 85 (82.52) | 103 (100.00) | ||
*Statistically significant. MRS=Menopause rating scale
Discussion
In the present study, the mean age of the study participants was found to be 53.86 ± 7.15 (SD) years. Similar findings were seen in studies done by Christian et al., Khan et al., Mazhar and Rasheed, Rahman et al., Rahman et al., Misiker et al. (2023) where the mean age of the respondents were 58.32 years, 58.14 ± 8.45 years, 56 years, 50.83 ± 6.30 (SD) years, 54.50 ± 5.70 (SD) years, 53.80 ± 5.786 (SD), respectively.[14,15,17,18,19,20]
In the present study, the mean age at natural menopause was found to be 46.77 ± 3.52 (SD) years. Similarly, Christian et al. reported mean age of menopause to be 47.74 years.[14] A similar study conducted in Tamil Nadu by Dutta et al. reported the mean age at menopause to be 44.49 years.[21] Similarly, Mazhar and Rasheed conducted a study in Islamabad, Pakistan and reported mean age at menopause to be 48.5 years.[19] Likewise, Ashrafi et al. reported the mean age at natural menopause to be 47.71 years.[22] In another similar study conducted at University of Ruhuna, Sri Lanka, by Rathnayake et al., the mean age at menopause was reported to be 48.3 ± 3.9 (SD) years.[23] The similarity in the mean age at natural menopause could be due to similar socio-cultural, racial, genetic, climatic and geographical factors which India shares with countries like Pakistan, Bangladesh, etc., On the contrary, higher age at natural menopause was reported by studies conducted in developed countries such as USA and UK. Gold et al. reported median age at natural menopause to be 51.4 years.[24] In a similar study done by Hardy and Kuh in England, Scotland and Wales, median age at natural menopause was found to be 52 years and 11 months.[12]
Socio-economic factors
In the present study, it was found that illiterate females experienced severe menopausal symptoms as compared to literate women, the difference being statistically significant. Similar findings were seen in study conducted by Wang et al. in Gansu province of China, where higher level of education was negatively associated with severity of symptoms.[25] In contrast, study conducted by Sánchez-Zarza et al. among middle aged Paraguayan women reported that higher level of education was significantly associated with more severe symptoms.[26] The most probable reason behind this might be that education predisposes to greater awareness level and thus results in a much better perception of severity of symptoms. Also, with regard to occupation, the present study reported that housewives experience more severe symptoms than working women. Likewise, Capistrano et al. conducted a study in Rio de Janeiro city, Brazil and reported that unemployed women and housewives presented higher prevalence of menopausal symptoms compared with working women.[27] The most probable explanation could be that being engaged in some sort of work can divert attention and can subjectively reduce severity of symptoms.
Rural and urban variation
As far as residing locality is concerned, the present study reported that urban dwellers experienced more severe menopausal symptoms than the rural inmates and this difference was statistically significant. Findings similar to this study were also reported by Shilpa and Ugargol.[28] On the contrary, Dasgupta and Ray reported that the prevalence of menopausal symptoms was 2–3 times higher in rural than the urban women.[29]
In the current study, association of severity of menopausal symptoms with marital status and socio- economic class was found not to be statistically significant. Similar finding was reported by Capistrano et al.[27] However, in contrast to this, Wang et al. reported that unmarried females experience greater severity of menopausal symptoms and higher level of family income was found to be negatively associated with severe symptoms.[25]
Physical activity/exercise
In the present study, it was found that women who were not engaged in any kind of exercise experienced severe menopausal symptoms than the women who were regularly engaged in some kind of exercise and the difference was statistically significant suggesting that exercise helps in reducing the severity of menopausal symptoms. Findings of this study were supported by Mishra et al. who indicated that postmenopausal women, who engage in the comprehensive exercise program, benefit by maintaining a healthy body, bone density levels, good mental health and reduced symptom severity.[30] de Azevedo Guimaraes and Baptista concluded that the habitual practice of at least moderate-intensity physical activity for 60 min/day has a favorable effect on menopause symptoms and on quality of life, particularly on its psychological and social domains.[31] Similarly, Kim et al. showed that perimenopausal women who performed moderate physical activity reported significantly lower psychosocial and physical symptoms than women who performed low physical activity.[32] However, no associations were observed between physical activity and the vasomotor and sexual symptoms. Likewise, Wang et al. also reported that physical activity was found to be inversely related to severity of menopausal symptoms.[25] Similarly, Sánchez-Zarza et al. also reported that severity of menopausal symptoms increases with sedentary lifestyle.[26] The most probable reason behind this could be that exercise helps in maintaining an appropriate metabolism of the body thus maintaining hormonal balance in the body as well. It releases endorphins which relaxes and soothes the mind and body and gives a feeling of happiness.
Tobacco consumption
In the present study, it was found that women who had history of tobacco addiction experienced severe menopausal symptoms than those who did not and this difference was statistically significant. Similarly, Capistrano et al. reported that the prevalence of women who smoke (tobaccoism) presenting with moderate to severe symptoms was 1.45 times higher than in non-smokers (probability ratio 1.45; confidence interval 95% 1.10–1.90; P < 0.01).[27]
Body mass index
The current study shows no significant association between BMI and severity of menopausal symptoms. Similar finding was reported by Capistrano et al.[27] Contrary to this, Wang et al. reported that higher BMI is associated with more severe symptoms.[25]
Parity
In the current study, no significant association was found between parity and severity of menopausal symptoms. Contrary to this, Wang et al. reported that number of pregnancies (parity) was found to be positively associated with severity of menopausal symptoms.[25] Sánchez-Zarza et al. also reported that more severe symptoms were associated with higher parity.[26] The most probable reason for this could be that the association between vaginal delivery and urinary incontinence lies in structural changes in the pelvic floor as well as repeated injury in muscles, nerves and connective tissue of the pelvic floor during childbirths.
Duration since menopause
The current study reported that more than 10 years duration since menopause was found to be associated with severe symptoms than less than 10 years duration and difference was statistically significant. Contrary to this, Capistrano et al. observed that the prevalence of women with moderate to severe symptoms within 6–10 years of menopause was 1.4 times higher than among those with more than 10 years past menopause.[27]
Dietary Factors
The present study did not find a significant association between dietary habits and menopausal symptom. This suggests that while diet may play a role in menopausal health, its impact on symptom severity may be limited. However, Natarajan J et al (2013)[33] suggested that dietary changes, including adoption of a vegetable-based diet is associated with less frequent, milder hot flashes. Also any dietary triggers like alcohol, caffeine, smoking, hot and spicy foods must be avoided.
Psycho-social factors
Regarding psycho-social factors, the present study reported that living alone and history of any untoward life incidence significantly affects the severity of the menopausal symptoms. Present study also highlights that the symptom severity varies with exposure to noise pollution and diurnally, the difference being statistically significant. Similar findings were reported by Blümel et al. where they concluded that negative vital events and family dysfunction increase in minor intensity the risk of anxiety, depression and stress.[34] Similarly, in the study conducted by Sánchez-Zarza et al., it was found that history of sexual abuse was associated with severe menopausal symptoms. Thus, negative psycho-social environment may affect the severity of menopausal symptoms.[26]
Strength and limitations
The strength of this study is that it highlights the factors which might influence the severity of menopausal symptoms and thus can help in finding better ways to mitigate sufferings of the climacteric period effectively which are often neglected. The limitation of this study is that it is a hospital-based study and thus study participants are not representative of the community.
Conclusion
The present study concludes that residing locality, educational status, occupation, living alone, exercise, history of tobacco addiction, noise exposure, time of the day (diurnal), any untoward life incidence, type of menopause and duration since menopause was found to be statistically significantly related to severity of menopausal symptoms.
Menopause is an important stage within the continuum of health in a woman’s life and is a phenomenon associated with symptoms instigating health conflicts, but it can’t be considered as disease or disorder. Therefore, menopause does not, under normal circumstances, require any kind of medical treatment or other interventions. However, in cases where the physical, mental and emotional impacts of menopause are strong enough that they significantly disrupt the everyday life of the women experiencing them, a comprehensive approach including health education and subjective counseling which will help in early recognition of transition phase from pre-menopause to menopause along with therapeutic interventions might be appropriate. Hence, it bestows a huge responsibility on the shoulders of primary care physicians to tackle the situation with appropriate wisdom and knowledge.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We extend our sincere acknowledgement towards the Professor and Head, Department of Obstetrics and Gynecology, Sultania Zanana Hospital, Bhopal and the study participants for their whole hearted cooperation in this study.
Funding Statement
Nil.
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