Abstract
Background:
Menopause-specific quality of life (MENQOL) in middle-aged women gives us an outline of ramifications of menopause in their life. This study was aimed at assessing the MENQOL among middle-aged women in urban Meerut and to determine the association of sociodemographic and lifestyle factors with MENQOL.
Material and Methods:
A cross-sectional study among middle-aged women was conducted in the urban area of Meerut. The estimated sample size was 300. Study subjects were selected by a multistage sampling method. Data collection was done using a pre-tested and semi-structured questionnaire. Association was assessed using the Chi-square test and logistic regression analysis.
Results:
Overall mean ± standard deviation score of MENQOL among study subjects was 3.1 ± 1.2. Women sleeping <5 hours in a day were 2.241 times more likely to have a poor quality of life (AOR: 2.241). In the psychosocial domain, lower middle class (AOR: 5.316) and lower class (AOR: 5.732) categories of socioeconomic classification revealed a robust association with poor psychosocial MENQOL in comparison with upper class women, with P values of 0.002 and 0.021, respectively. Tobacco users were significantly (P = 0.019) more likely (Adjusted odds ratio [AOR]: 4.247) to encounter a poor sexual quality of life.
Conclusions:
Half of the study participants had a good MENQOL, with significant differences in MENQOL among the different domains. It was found that shorter sleep duration impacted overall MENQOL. Domain-wise analysis showed socioeconomic status in the psychosocial domain and marital status, occupation, and tobacco usage in the sexual domain as significant predictors.
Keywords: India, lifestyle, menopause, MENQOL, quality of life, urban, women
INTRODUCTION
Menopause is the permanent cessation of menstruation due to loss of ovarian function.[1] Female hormones play a vital role in reproductive function and ensure cardioprotection and bone health. By middle age, the majority of women start experiencing physical, psychological, and emotional disturbances, eventually transitioning into menopause. A total of 1.2 billion women will be in menopause and postmenopause by 2030, with the addition of 47 million women/year globally.[2] To decrease disability in this cohort, it is imperative to improve their MENQOL. Thus, this study was done to assess MENQOL and to determine its association with sociodemographic and lifestyle factors among middle-aged women in urban Meerut.
MATERIALS AND METHODS
A community-based cross-sectional study was carried out among middle-aged women in the menopausal transition or postmenopausal stage residing in an urban area of Meerut, Uttar Pradesh, from September 1, 2023 to September 30, 2024. The sample size required for the study was calculated using the following formula:
Considering the prevalence of menopausal symptoms as 89.5% (the most common menopausal symptom in the study was physical symptoms; hence, its prevalence was taken into account) according to a study by Madan et al. (2019),[3] at 95% confidence interval, design effect value of 2 and with 5% absolute precision, the minimum calculated sample size came to be 289, which was rounded off to 300.
The sampling method of the study is elaborated in Figure 1. The ward number 58 consists of the following 10 mohallas – Vanshipura, Lakshminagar, Hanumanpuri, Gandhinagar, Saraswati mandir, Devinagar, Aryanagar, Surajkund road, Budh Vihar, and Rambagh. Budh Vihar, being a commercial area, was excluded since there were no registered residents in the ward data. The study was ethically approved by the institutional ethical committee of LLRM Medical College, Meerut, vide letter number: SC-1/2025/2957. A total of 300 study participants were interviewed and assessed after obtaining informed consent. Women who are in the reproductive phase or in the postmenopausal stage who have not attained a natural menopause, and those who were on any hormone replacement therapy or hormonal medications within the last 6 months were excluded from the study. Women who were known cases of chronic systemic diseases like diabetes mellitus, thyroid diseases, any psychiatric illness, cardiovascular disease, and/or any genital pathology were excluded from the study, as these conditions may have symptoms similar to the menopausal symptoms and can affect the study results. Also, illiterate women were excluded due to the requirement of self-administration in the menopause-specific quality of life (MENQOL) questionnaire. Confidentiality of information was maintained throughout the study.
Figure 1.
Sampling method
Data collection was done using a predesigned, pre-tested schedule and MENQOL questionnaire. A pilot study among 30 study participants was conducted for the pretesting of the schedule in Jai Bheem Nagar (Ward No. 13) of urban Meerut. The schedule collected information about the sociodemographic and lifestyle factors as well as awareness status of each study subject. MENQOL questionnaire measures both the degree and the severity of menopausal symptoms experienced by middle-aged women during the past month. The questionnaire has 29 items which assess the menopausal symptoms by dividing them into four domains: vasomotor domain (three items), psychosocial domain (seven items), physical domain (16 items), and sexual domain (three items). For each item of the MENQOL questionnaire, a score was given from 1 to 8. The scores were added, and the mean score of each domain was calculated. The overall questionnaire score was the mean score of the domain means.
The data collected was coded and transferred to a master chart in Microsoft Excel. The distribution as well as association tables were prepared, analyzed, and statistically evaluated using Jamovi 2.3.28 software. Descriptive statistics such as frequency and percentages were used for qualitative data, and mean with standard deviation and median and interquartile range were used for quantitative data. Association was assessed using the Chi-square test, and P value of <0.05 was taken as statistically significant. Logistic regression analysis was used to predict the final model with significant factors affecting the MENQOL.
RESULTS
Mean age of the study subjects was 49.1 ± 6.8 years. Mean age of menopause among the study participants in the postmenopausal stage was 44.5 ± 5.2 years. The mean duration of postmenopause in postmenopausal study subjects is 7.6 ± 4.8 years. It was noted that all the women in the menopausal transition stage were aged ≤50 years, i.e., by the age of 50 years all the study subjects had achieved menopause. Table 1 interprets the MENQOL scoring among different domains.
Table 1.
Domain-wise average scores of menopause-specific quality of life among middle-aged women
| Domain | Mean±SD | Median (IQR) | ||
|---|---|---|---|---|
| Vasomotor | 3.4±2.4 | 2.8 (1.0–5.7) | ||
| Psychosocial | 3.4±1.5 | 3.3 (2.1–4.4) | ||
| Physical | 3.0±1.1 | 2.9 (2.1–3.8) | ||
| Sexual | 2.4±1.7 | 1.7 (1.0–3.0) | ||
| Overall | 3.1±1.2 | 3.0 (2.0–3.9) |
IQR=Interquartile range, SD=Standard deviation
MENQOL was graded into good and poor, considering the mean MENQOL score of the study subjects as the cut-off, which was 3.1. Those who scored equal to or below 3.1 were considered to have a good MENQOL, and those who scored more than 3.1 were considered to have a poor MENQOL. Figure 2 illustrates the domain-wise distribution of MENQOL. There was a fairly significant difference between good and poor MENQOL among different domains of MENQOL (Χ2: 57.86; P value < 0.001).
Figure 2.
Distribution of menopause-specific quality of life (n = 300)
Factors affecting menopause-specific quality of life
Table 2 describes the distribution of sociodemographic and lifestyle factors and their association with overall MENQOL.
Table 2.
Association of menopause-specific quality of life with sociodemographic and lifestyle factors among middle-aged women (n=300)
| Factors | Good MENQOL n (%) | Poor MENQOL n (%) | Total n (%) | P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
Sociodemographic factors | ||||||||||
| Age (in years) | ≤50 | 102 (52.0) | 94 (48.0) | 196 (65.3) | 0.76 | |||||
| >50 | 56 (53.8) | 48 (46.2) | 104 (34.7) | |||||||
| Education Level | Primary school | 69 (48.6) | 73 (51.4) | 142 (47.3) | 0.09 | |||||
| Middle school | 22 (43.1) | 29 (56.9) | 51 (17.0) | |||||||
| High school | 21 (56.8) | 16 (43.2) | 37 (12.3) | |||||||
| Intermediate/Post high school | 15 (62.5) | 9 (37.5) | 24 (8.0) | |||||||
| Graduate and above | 31 (67.4) | 15 (32.6) | 46 (15.3) | |||||||
| Marital Status | Married and living with spouse | 110 (50.0) | 110 (50.0) | 220 (73.3) | 0.12 | |||||
| Separated/Widow | 48 (60.0) | 32 (40.0) | 80 (26.7) | |||||||
| Occupation | Unemployed | 36 (50.0) | 36 (50.0) | 72 (24.0) | 0.84 | |||||
| Employed | 52 (52.5) | 47 (47.5) | 99 (33.0) | |||||||
| Homemaker | 70 (54.3) | 59 (45.7) | 129 (43.0) | |||||||
| Socioeconomic status | Upper class | 12 (50.0) | 12 (50.0) | 24 (8.0) | 0.11 | |||||
| Upper middle class | 44 (59.5) | 30 (40.5) | 74 (24.7) | |||||||
| Middle class | 55 (57.3) | 41 (42.7) | 96 (32.0) | |||||||
| Lower middle class | 43 (47.3) | 48 (52.7) | 91 (30.3) | |||||||
| Lower class | 4 (26.7) | 11 (73.3) | 15 (5.0) | |||||||
|
Lifestyle factors | ||||||||||
| Type of diet | Less spicy | 36 (48.0) | 39 (52.0) | 75 (25) | 0.02 | |||||
| Normal spicy | 103 (58.9) | 72 (41.1) | 175 (58.3) | |||||||
| Very spicy | 19 (38.0) | 31 (62.0) | 50 (16.7) | |||||||
| Tobacco usage | Present | 6 (35.3) | 11 (64.7) | 17 (5.7) | 0.14 | |||||
| Absent | 152 (53.7) | 131 (46.3) | 283 (94.3) | |||||||
| Exercise duration in a week | Nil | 83 (50.3) | 82 (49.7) | 165 (55) | 0.63 | |||||
| <150 minutes of moderate/75 minutes of vigorous exercise | 43 (56.6) | 33 (43.4) | 76 (25.3) | |||||||
| ≥150 minutes of moderate/75 minutes of vigorous exercise | 32 (54.2) | 27 (45.8) | 59 (19.7) | |||||||
| Sleep duration in a day | <5 hours | 23 (34.3) | 44 (65.7) | 67 (22.3) | 0.003 | |||||
| 5–8 hours | 110 (57.9) | 80 (42.1) | 190 (63.4) | |||||||
| >8 hours | 25 (58.1) | 18 (41.9) | 43 (14.3) | |||||||
MENQOL=Menopause-specific quality of life
Association of sociodemographic and lifestyle factors was further analyzed in each of the four domains of MENQOL separately using the Chi-square test. Marital status (P value < 0.001), occupation (P value < 0.001), and tobacco usage (P value = 0.02) revealed significant association with MENQOL in the sexual domain. Tobacco usage was the only factor that was significantly associated with MENQOL in the physical domain, with a P value of 0.02. Socioeconomic status (P value < 0.001) and sleep duration (P value = 0.007) showed a fairly strong association with the psychosocial domain of MENQOL. MENQOL in the vasomotor domain was not associated statistically with any of the factors considered in the study.
Logistic regression analysis
After applying the Chi-square test, the significant factors (P < 0.05) affecting MENQOL were identified and analyzed using univariate logistic regression (univariable and multivariable analysis). Table 3 depicts the regression analysis of predictor variables affecting MENQOL.
Table 3.
Predictors affecting menopause-specific quality of life (n=300)
| Variables | Odds ratio | 95% CI | SE | Z | P | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||||||||
| Unadjusted | Adjusted | lower | upper | |||||||||||||
|
Overall MENQOL | ||||||||||||||||
| Type of diet | Less spicy | 1.550 | 1.551 | 0.854 | 2.815 | 0.304 | 1.442 | 0.149 | ||||||||
| Normal spicy | Reference | – | – | – | – | – | – | |||||||||
| Very spicy | 2.334 | 1.816 | 0.895 | 3.68 5 | 0.361 | 1.651 | 0.099 | |||||||||
| Sleep duration in a day | <5 hours | 2.630 | 2.241 | 1.209 | 4.151 | 0.315 | 2.564 | 0.010 | ||||||||
| 5–8 hours | Reference | – | – | – | – | – | – | |||||||||
| >8 hours | 0.990 | 1.057 | 0.509 | 2.195 | 0.373 | 0.148 | 0.882 | |||||||||
|
Psychosocial domain | ||||||||||||||||
| Socioeconomic status (Modified B G Prasad) | Upper class | Reference | – | – | – | – | – | – | ||||||||
| Upper middle class | 2.353 | 2.062 | 0.751 | 5.659 | 0.515 | 1.405 | 0.160 | |||||||||
| Middle class | 1.840 | 1.466 | 0.543 | 3.961 | 0.507 | 0.755 | 0.450 | |||||||||
| Lower middle class | 5.913 | 5.316 | 1.895 | 14.915 | 0.526 | 3.174 | 0.002 | |||||||||
| Lower class | 5.500 | 5.732 | 1.302 | 25.240 | 0.756 | 2.308 | 0.021 | |||||||||
| Sleep duration in a day | <5 hours | 1.960 | 1.744 | 0.923 | 3.296 | 0.325 | 1.713 | 0.087 | ||||||||
| 5–8 hours | Reference | – | – | – | – | – | – | |||||||||
| >8 hours | 0.559 | 0.701 | 0.340 | 1.444 | 0.369 | −0.963 | 0.336 | |||||||||
|
Physical domain | ||||||||||||||||
| Tobacco usage | Present | 3.213 | 2.554 | 0.829 | 7.872 | 0.574 | 1.633 | 0.102 | ||||||||
| Absent | Reference | – | – | – | – | – | – | |||||||||
|
Sexual domain | ||||||||||||||||
| Marital Status | Married and living with spouse | 4.373 | 4.295 | 1.714 | 10.763 | 0.469 | 3.109 | 0.002 | ||||||||
| Seperated/Widow | Reference | – | – | – | – | – | – | |||||||||
| Occupation | Unemployed | 2.544 | 2.909 | 1.235 | 6.850 | 0.437 | 2.443 | 0.015 | ||||||||
| Employed | Reference | – | – | – | – | – | – | |||||||||
| Homemaker | 2.867 | 2.550 | 1.236 | 5.262 | 0.370 | 2.533 | 0.011 | |||||||||
| Tobacco usage | Present | 3.042 | 4.247 | 1.274 | 14.154 | 0.614 | 2.354 | 0.019 | ||||||||
| Absent | Reference | – | – | – | – | – | – | |||||||||
CI=Confidence interval; MENQOL=Menopause-specific quality of life; SE=Standard error
Women sleeping less than 5 hours in a day were 2.241 times more likely to have a poor quality of life [AOR: 2.241, (CI: 1.209–4.151)] than women sleeping for 5–8 hours in a day (P = 0.010). Women belonging to the lower middle class [AOR: 5.316, (CI: 1.895–14.915)] and lower class [AOR: 5.732, (CI: 1.302–25.240)] categories of socioeconomic classification revealed a robust association with poor psychosocial MENQOL in comparison with upper class women, with P values of 0.002 and 0.021, respectively. Married women living with their spouse had 4.295 times [AOR: 4.295, (CI: 1.714–10.763)] higher odds of experiencing poor MENQOL in the sexual domain compared to separated or widowed women (P = 0.002). Unemployed women [AOR: 2.909, (CI: 1.235–6.850)] and homemakers [AOR: 2.550, (CI: 1.236–5.262)] revealed a fairly higher risk of having a poor sexual MENQOL than employed women. Tobacco users were significantly (P = 0.019) more likely [AOR: 4.247, (CI: 1.274–14.154)] to encounter a poor sexual quality of life compared to non-tobacco users.
DISCUSSION
Menopause has become a relevant topic for not only clinicians but also public health experts and health policymakers with the general increase in life expectancy. Women are likely to live for more than 20 years after menopause in an estrogen-deprived state with impaired quality of life due to menopausal symptoms.[4] Present study noted that 48.5% of postmenopausal women were ≤50 years of age and 51.5% of postmenopausal women were >50 years of age. All the women aged >50 years were in the postmenopausal stage in our study. Similar findings were found by Ajmera et al. (2022)[5] in a cross-sectional study among urban and rural postmenopausal women of Gurugram. The mean age and standard deviation for age at menopause were 48.10 ± 2.86 for urban women. Thus, 50 years can be used as a reliable cut-off for initiating postmenopausal health strategies.
The current study depicted that MENQOL domain-wise mean ± standard deviation scores were 3.4 ± 2.4, 3.4 ± 1.5, 3.0 ± 1.1, and 2.4 ± 1.7 in vasomotor, psychosocial, physical, and sexual domains, respectively, indicating that vasomotor and psychosocial domains were more affected than physical and sexual domains. On the other hand, the study by Senthilvel et al. (2018)[6] in Kochi pointed out that the vasomotor and sexual domains were less frequently affected when compared to physical and psychological domains. Meanwhile, the research by Madan et al. (2019)[3] described lower domain-wise mean ± standard deviation scores than the present study in vasomotor, psychosocial, physical, and sexual domains as 2.1 ± 1.6, 2.3 ± 1.4, 3.1 ± 0.9, and 1.4 ± 1.1, respectively.
The majority of the participants had a good MENQOL in vasomotor (53.3%), physical (55.7%), and sexual (76%) domains in our study. In the psychosocial domain, a small majority of women (57.7%) had poor MENQOL. There was a fairly significant association between the grading and different domains of MENQOL (Χ2: 57.86; P value < 0.001).
The current research revealed that in the vasomotor domain, women who were taking a normal and less spicy diet predominantly felt good quality of life compared to women consuming a very spicy diet. A significant statistical association was noted between type of diet and overall MENQOL (P value: 0.02). Thus, it is important to consider dietary habits while advising menopausal women.
Tobacco usage was significantly associated with physical and sexual domains of MENQOL with a P value of 0.02 in each of these domains in the present study. In accordance with this, a study by Hajj et al. (2020)[7] among women of the Mediterranean region showed a statistically significant association between smoking and MENQOL and its subdomains. By contrast, Singh et al. (2023)[8] observed that females who were consuming tobacco had better quality of life in psychosocial, physical, and sexual domains.
There was no statistically significant association between exercise duration and MENQOL among the current study subjects. However, Hajj et al. (2020),[7] in a study on Lebanese women, showed that physical activity enhances the quality of life among menopausal women. Singh et al. (2023)[8] also found that those who were physically active had better quality of life in psychosocial, physical, and sexual domains in their research among middle-aged females of Dehradun, Uttarakhand. This association of MENQOL with exercise is observed due to the fact that endorphins are released during exercise, which helps in stress reduction.
Association of sleep duration of menopausal women with overall MENQOL and in the psychosocial domain was found to be significant with P value of 0.003 and 0.007, respectively, in the study. This was corroborated by the findings of Gupta et al. (2024)[9] that MENQOL score was higher for those who were not getting enough sleep as compared to those who were getting enough sleep.
In the present study, after logistic regression analysis, it was found that shorter sleep duration of menopausal women significantly impacted overall MENQOL. Women sleeping less than 5 hours in a day were 2.241 times more likely to have a poor quality of life [AOR: 2.241, (CI: 1.209–4.151)] than women sleeping for 5–8 hours in a day (P = 0.010). Domain-wise analysis revealed that lower middle class [AOR: 5.316, (CI: 1.895–14.915)] and lower class [AOR: 5.732, (CI: 1.302–25.240)] categories of socioeconomic status showed a robust association with poor psychosocial MENQOL in comparison with upper class women, with P values of 0.002 and 0.021, respectively. Factors significantly associated with the sexual domain of MENQOL were marital status, occupation, and tobacco usage after regression analysis. Women who were married and living with their spouse were 4.295 times [AOR: 4.295, (CI: 1.714–10.763)] more likely to experience a poor MENQOL in the sexual domain compared to separated or widowed women (P = 0.002). Unemployed women had 2.909 times [AOR: 2.909, (CI: 1.235–6.850)] higher odds of experiencing poor sexual quality of life than employed women (P = 0.015). Homemakers were also significantly associated with poor sexual quality of life (P = 0.011), with 2.550 times more risk [AOR: 2.550, (CI: 1.236–5.262)] than employed women. Tobacco users were significantly (P = 0.019) more likely [AOR: 4.247, (CI: 1.274–14.154)] to encounter a poor sexual quality of life compared to non-tobacco users. On the contrary, Nair et al. (2024)[10] found that occupation (employed) showed a significant association with quality of life of menopausal women in the vasomotor domain [AOR: 2.07, (CI: 1.05–4.09)]. Marital status [single, AOR: 3.09, (CI: 1.42–6.69)] also showed a statistically significant association in the physical domain of MENQOL.
CONCLUSIONS
Almost half of the study participants had a poor MENQOL, with a significant difference in the distribution of good and poor MENQOL among vasomotor, psychosocial, physical, and sexual domains of MENQOL. After logistic regression analysis and adjusting for confounding factors, it was found that less than 5 hours of sleep in a day significantly impacted overall MENQOL. Domain-wise analysis showed socioeconomic status in the psychosocial domain, and marital status, occupation, and tobacco usage in the sexual domain were the significant predictors of MENQOL.
Recommendations
Estimation of menopausal women and their statistics at national or state levels is solely based on the average age of menopause and projecting the data on the women population above that age. Since national surveys like NFHS don’t incorporate middle-aged women, it is necessary to plan and conduct demographic surveys of middle-aged women at the national level and inclusion of menopausal health component in National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) or National Health Mission (NHM) programs. Lifestyle interventions, counseling, and wherever appropriate, hormonal therapy, customized to each stage of menopausal transition and postmenopause, can be provided by conducting menopausal clinics at the primary level of healthcare. Menopausal women should be counseled about the importance of a balanced, moderate-spice and nutrient-rich diet for a better MENQOL. Certain foods like fat-free milk, green vegetables, amla, citrus fruits, ragi, fish, legumes, and soyabeans can be included in their diet. Women should be encouraged to engage in regular physical activity and yoga as it can improve mental health and enhance overall well-being. Menopause-related educational materials that are accessible to women with lower literacy levels can be designed, and the promotion of peer education and community awareness initiatives on menopause. Further research should be promoted and funded on the causation and mechanism by which sleep duration, tobacco usage, and diet are influencing the MENQOL.
Limitations
Women with chronic systemic diseases (diabetes, thyroid, CVD, psychiatric illness) were excluded from the study, but these conditions are highly prevalent in middle-aged women and can impact quality of life along with menopausal changes. Thus, it may affect the generalizability of the study to some extent.
Out of the 300 middle-aged women surveyed, none of the study participants had the habit of consuming alcohol. Thus, we were not able to assess the association of alcohol use with MENQOL. Only 5.7% (17/300) of menopausal women used tobacco, of which 0.7% were using smoked tobacco, and 5% were using smokeless tobacco. The results were derived from a small sample of tobacco users; hence, it may affect its accuracy. On assessing the sexual domain of MENQOL in widowed/separated women, questions related to vaginal dryness during sexual intercourse and avoiding intimacy might have a biased or incorrect response when we consider marital status as a variable affecting sexual MENQOL.
The logistic regression variable selection strategy used in the study is P value-based, which is known to have limitations for confounder control.
Key messages
Proper planning and conduction of demographic surveys for middle-aged women at the national level and inclusion of the menopausal health component in NP-NCD or NHM programs is very crucial for the betterment of MENQOL among Indian women.
Shorter sleep duration (<5 hours a day), lower socioeconomic status, and occupation of menopausal women significantly impacted their MENQOL.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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