Introduction:
Menopause is a natural transition result in the depletion of estrogen levels as women approach middle-age[1]. The limited estrogen level may lead to the development of vasomotor, psychological, somatic, and atrophic changes in the estrogen-dependent tissues, which contribute to the so-called menopausal (climacteric) syndrome. These physiological and pathological alterations may exert a negative effect on women’s quality of life, and even cause severe physical and mental illness[2]. Unfortunately, in our society, the majority of these women are not aware of the changes brought about by menopause[3]. It is estimated that in the world wide nearly 85 % of postmenopausal women have experienced menopause-related symptoms in their lifetime[4]. In 2030, nearly half of females will become postmenopausal and by 2060, the proportion of postmenopausal women will be increased up to 59.8%[5]. The prevalence of vasomotor symptoms alone is estimated at approximately 40 to 50 million women in the United States[6] whereas In India the prevalence of vasomotor symptom is 60.7% among women and it is experienced in the form of hot flushes and night sweating[7].
As women complete the transition to menopause, 85% of women report at least one menopausal symptom, and only 10% of these women would seek healthcare[8]. There is evidence of differences in the prevalence and composition of menopausal symptoms between Asian and Caucasian women. In Europe and North America, the most common symptoms reported by women during the menopause transition are hot flushes and night sweats, which affect approximately 70% of women[9]. It has always been believed and reported that vasomotor symptoms dominate the menopausal symptomatology among Western women whereas, musculoskeletal symptoms along with sleeplessness predominate among Asian women and these findings are confirmed by research studies over many decades[10-12]. Studies on menopause from western countries have reported a higher prevalence of physical and psychological symptoms around menopause[13]. Therefore in most developed countries hormone replacement therapy (HRT) is often recommended to prevent these distressing symptoms[14]. There are no sufficient studies on issues relating to the effect of menopause on women, and the feasibility and impact of HRT in health-care system in India. The present study was carried out to determine the mean age of menopause and the prevalence of menopause and menopausal symptoms in South Indian women. According to literature, at least 60% of ladies suffer from mild symptoms and 20% suffer severe symptoms and 20% from no symptoms. The present study was undertaken from the three PHC’s of Mangalore Taluk called, Mudipu, Natekal and Kotekar with a service approach to give health-care advice to the needy. So the current study was conducted to know the prevalence of menopausal symptoms at Mangalore Taluk.
Methods
Study design and participants
A community-based cross-sectional study was carried to assess the prevalence of menopausal symptoms. The study was conducted at three Primary Health Centres of Mangalore Taluk, viz. Kotekar, Natekal and Mudipu. The sample consisted of 1034 menopausal women aged between 48–55 years. The sample was selected using random stratified sampling technique from 16 sub-centers under the afore said PHC. The inclusion criteria for the study was the participants age [between 48-55 years] and the exclusion criteria for study participants were participants with surgical menopause, receiving any kind of hormone replacement therapy or anticoagulant therapy, participants with anxiety or mood disorders, depression, schizophrenia, diabetes, hypertension, and cardiac diseases.
Data collection instruments
The data were collected using the socio-demographic proforma and self-reported menopausal symptom checklist. The socio-demographic proforma consists of six items such as the age of the women, age at which menopause attained, educational status, nature of work of women, previous knowledge regarding menopause, and any history of gastrointestinal disorders. The self-reported menopausal checklist consists of 29 items which were classified under five domains namely, vasomotor, psychosocial, physical, sexual and genitourinary domains used to allot the samples into the study group. The items in the self-reported menopausal symptom checklist were classified and scored as mild, moderate, and severe menopausal symptoms.
Sample size calculation
The sample size was calculated using power analysis and the calculation of sample size for the prevalence of menopausal symptoms was done using the technique of estimating proportion.
The calculated sample size for assessing the prevalence of menopausal symptoms among women between 48-55 years is 1034.
Ethical considerations
The study was reviewed and approved by the Institutional Ethics Committee and Central Ethics committee of the NITTE (Deemed to be University). The present study fits into the principles defined in the Declaration of Helsinki12 (World Medical Association, 2013). The study protocol was registered in CTRI and the number is CTRI/2017/07/009071.
Data collection procedure
Before the data collection, each participant was explained the nature and purpose of the study. Informed written consent was administered to the participants to assure confidentiality of data among the participants. The menopausal women were approached by the ASHA workers at their houses. Each participant was asked regarding the experience of menopausal symptoms listed down in the self-reported menopausal symptom checklist in the previous one month period.
Data analysis
The data from the socio-demographic proforma and self-reported menopausal symptom checklist were included in the data analysis. Analysis was performed using Statistical Package for Social Sciences software package SPSS software version11.0 (SPSS Inc., Chicago, IL). SPSS 20 for Windows was used to analyze the data. A descriptive analysis was used to describe the characteristics of the participants as well as the menopausal symptoms.
Result
Baseline information
| Table 1- Frequency (f) and percentage (%) distribution of demographic variables of participants |
| Demographic characteristics (n=1034) |
Frequency (f) |
Percentage (%) |
| Age in years |
48-50 |
481 |
46.5 |
51-53 |
340 |
32.8 |
54-55 |
213 |
20.5 |
| Age at menopause |
45-46 |
379 |
36.6 |
47-48 |
543 |
52.5 |
49-50 |
112 |
10.83 |
| Educational status of women |
Primary education |
173 |
16.7 |
High school education |
640 |
61.8 |
Higher secondary education |
221 |
21.3 |
| |
|
|
| Nature of work of women |
Unemployed |
647 |
62.5 |
Un skilled worker |
268 |
25.9 |
Semi-skilled worker |
119 |
11.5 |
| Income status of women per month (In Rupees) |
>2,424 |
671 |
64.8 |
2,423-6,662 |
246 |
23.7 |
6,663-11,103 |
117 |
11.3 |
| Marital status of women |
Single |
11 |
1.06 |
Married |
981 |
94.8 |
Widow |
26 |
2.51 |
Separated |
16 |
1.54 |
| Type of family |
Nuclear family |
812 |
78.5 |
Joint family |
202 |
19.5 |
Extended family |
20 |
1.9 |
| Do you have any information regarding menopause and its management |
Yes |
488 |
47.19 |
No |
546 |
52.8 |
| If yes, Source of information |
Health professional |
233 |
47.7 |
Family members |
156 |
31.9 |
Television |
99 |
20.2 |
| Do you have any gastrointestinal disorders such as diarrhoea, vomiting, bloating, and gastritis at present? |
Yes |
300 |
29.1 |
No |
734 |
70.9 |
In the present study, 47% of the women to the age group of 48–50 years and the average age for menopausal women are 49.8 ± 1.51 years with a minimum age 48 years and maximum age 55 years. The average age of attaining menopause was 48.26 years. Sixty - two percent of the study population had a high school level of education, and the majority of them were unemployed (63%) and they drew an earning of > 6,662 (65%). Ninety-five percent were married, and 79% of them belonged to nuclear families. Forty-six percent of them belonged to lower socioeconomic status. Forty-eight percent of them had previous education regarding menopause and its management and they obtained the information from health professionals, family members, and social media (Television).
Prevalence of menopausal of symptoms
Vasomotor Domain
| Table 2- Frequency (f) and percentage (%) distribution of Menopausal symptoms – Domain wise. |
| Symptoms |
Frequency (f) |
Percentage (%) |
Hot flushes |
861 |
83.2 |
Night sweats |
739 |
71.4 |
Profuse sweating along with hot flushes |
123 |
11.89 |
The most common symptom reported under the domains of vasomotor is hot flushes. About eighty –three percent [861] of the participants are experiencing with hot flushes, followed by, seven hundred and thirty nine [71%] participants are reported with night sweats. The mean score and S.D of vasomotor symptoms reported by participants was 7.6 ± 2.8.
Psychosocial Domain
| Symptoms |
Frequency (f) |
Percentage (%) |
Dissatisfaction with personal life |
315 |
30.4 |
Feeling anxious |
538 |
52.03 |
Forgetfulness |
743 |
71.8 |
Difficulty in concentrating |
419 |
40.5 |
Feeling depressed |
259 |
25.04 |
Impatient with other people |
415 |
40.1 |
Wanting to be alone |
458 |
44.2 |
Irritability |
295 |
28.5 |
The most common psychosocial symptoms experienced by menopausal women were forgetfulness, 743 [72%] followed by feeling anxious, 538 [52%]. The most prevalent symptoms like difficulty in concentrating, impatient with other people and wanting to be alone was 40 ± 4.2. The least psychosocial symptoms were reported by menopausal women were dissatisfaction with personal life [30.4%], irritability [28.5%] and feeling depressed [25.04%].
Physical Domain
| Symptoms |
Frequency (f) |
Percentage (%) |
Joint pain |
175 |
16.6 |
Lack of energy |
737 |
71.2 |
Tiredness |
824 |
79.6 |
Weight gain |
417 |
40.3 |
Difficulty in sleeping |
625 |
60.4 |
Changes in the texture of the skin |
205 |
20 |
Dry and itching skin |
130 |
13.5 |
Hyper pigmentation of the skin |
172 |
16.6 |
The most reported physical symptoms among study participants were tiredness, 824 [80%], lack of energy 737 [71.2%] and difficulty in sleeping, 625 [60%]. The mean and S.D of symptoms like joint pain and hyper pigmentation of the skin was 16 ± 1.2. With regards to the changes in the integumentary system 20% of the participants reported changes in the texture of the skin and 13.5% reported dry and itching skin.
Genito Urinary Domain
| Symptoms |
Frequency (f) |
Percentage (%) |
Frequent urination |
170 |
16.4 |
Urinary tract infections |
82 |
7.9 |
The least reported domains of menopausal symptoms were frequent urination and urinary tract infections. Only 16.4% of the participants reported with frequent urination whereas, merely 8% of the participants had the history of urinary tract infections.
Sexual Domain
| Sexual complaints |
Frequency (f) |
Percentage (%) |
Changes in sexual desire |
849 |
82.1 |
Pain during sexual intercourse |
634 |
61.3 |
Vaginal dryness |
594 |
57.4 |
Nearly everyone reported Sexual domains of menopausal symptoms. Under the sexual complaints, 82% of the participants reported changes in the sexual desire [849]. Whereas, pain during sexual intercourse was reported by 61.3% and vaginal dryness reported by 57.4% of the study participants.
Discussion
The present study shows the baseline information that, 47% of the study participants were in the age group of 48–50 years and the average age among the women were 49.8 ± 1.51 years with a minimum age 48 and maximum age 55 years. The average age of attaining menopause in the present study was 48.26 years. Similar findings were shown in a research study conducted by Karar P et al[15] (2015) in India reported that, the mean age of the participants among Tribes were 49.09 ± 4.7 and Caste were 48.85 ± 4.2 with p value 0.052. The minimum age among the study participants between 40 and 55 years. The mean age at menopause attainment among Tribe was 42.69 ± 5.6 and Caste was 40.65 ± 5.0. The present study, almost comparable to the report of Bairy L et al[16] (2009) in India observed that, the mean age of menopause was 48.67. However, there is a wide range in mean age regarding attainment of menopause between Indian women (40.3 to 48.8 years) as well as western women (48 to 51 years).
In the present study, majority of (64.8%) of menopausal women were drawing about Rs. >2,424/- and 23.7% of them were drawing an amount Rs. 2,423 - 6,662/-. These findings were comparable with the study findings by Karamkar et al[17] (2017), 46% of menopausal women drawing an amount of >773/- and they are with lower socio economic status. Nearly, 91% of menopausal women were drawing an amount of Rs. 773-1546/- and they are considered as upper lower socio economic status. The study findings revealed that, sixty - two percent of the study population had a high school level of education, and the majority of them were unemployed (63%), ninety-five percent were married, and 79% of them belonged to nuclear families. The study findings are consistent with another study conducted by Joseph, et al[18] (2006) reveals that, 70.5% of the menopausal women had high school education, 50.9 % of the study participants were house wives and 67.3% were married. These findings are in far with another study finding by Broker SA et al[19] (2013) in Kerala demonstrated that, 96.2% of the participants were educated with p value 0.787. With regards to the occupational status 88% of the menopausal women were unemployed with p value 0.0577. The baseline characteristics of the study concluded that, forty-eight percent of them had previous education regarding menopause and its management and they obtained the information from health professionals, family members, and social media (Television).
In the present study, the most common type of menopausal symptom under the domain vasomotor includes, hot flushes and night sweats. About eight –hundred and sixty nine [83%] of the participants were experiencing with hot flushes, followed by, seven hundred and thirty nine [71%] are reported with night sweats. Similar findings reported in a study conducted by Joseph et al[18] (2014) in Manipal, India reported that somatic problems reported among 96.4% of study participants. On the other hand, a study conducted by Bairy L et al[16] (2009) demonstrated that the vasomotor symptoms were less frequently reported and the incidence of hot flushes and excessive sweating were less (< 50%) among the study population.
The most reported psychosocial and physical symptoms experienced by menopausal women were forgetfulness - 743 [72%], feeling anxious - 538 [52%], tiredness - 824 [80%], lack of energy- 737 [71.2%] and difficulty in sleeping - 625 [60%]. Like our study, similar studies are reported that physical and psychosocial symptoms were highly in Asian women. The data in a study by Bairy L et al[16] (2009) demonstrated that study participants were more complained about physical symptoms than the other domains and the findings were, more than 50% of women complained of feeling tiredness (64.7%), poor memory (60.5%) and difficulty in sleeping (51.7%). The present study findings under the psychosocial domain were consistent with another study finding by Karamkar et al [17] (2017) reported that, feeling anxious or nervousness (94%), Lack of energy (88%) and difficulty in sleeping (84%) were more prevalent among study population.
In our study, the least reported domains of menopausal symptoms were frequent urination and urinary tract infections. Only 16.4% of the participants reported with frequent urination whereas, merely 8% of the participants had the history of urinary tract infections. The study findings are consistent with a study conducted by Bairy L et al[16] shows that, only 13% women are complained of having frequent urination. Present study reveals that, nearly everyone reported sexual symptoms during the journey through menopause and the sexual complaints were sexual desire, pain during sexual intercourse and vaginal dryness.
Conclusion
To conclude, the present study has shown that the prevalence of classical menopause symptoms like profuse sweating along with hot flushes, increased anxiety, depression wanting to be alone, frequent urination and urinary tract infections were lower but, vasomotor, psychosocial, physical and sexual symptoms like hot flushes, night sweats, tiredness, difficulty in sleeping, changes in sexual desire were the prominent symptoms among the study participants. The average age among the participants were 49.8 ± 1.51 and the average age of attaining menopause was 48.26 years. The high proportion and severity of the menopausal symptoms observed in this study group proves that menopausal symptoms are common and cannot be ignored. It is therefore suggested that menopausal clinics needs to be established within the current primary health care system so as to focus attention to menopausal women and their needs. Such clinics need to also create awareness among women who are approaching their menopause regarding early identification of common menopausal symptoms and its prompt management so that the severity of such symptoms could be minimized.
Implications of the study
Studies to date suggest that these kind of community surveys helps to serve several purposes. First and most importantly, they educate the participating women and create awareness that the menopausal symptoms are natural consequences of progressive life events. Many women mistake these symptoms as a part of serious systemic disease and waste lots of time, energy, effort and money on pursuing ineffective medical remedies. Understanding the physiology of menopause and its symptoms helps to cope more effectively. This study has significantly contributed to identify the predominant symptoms in the local community area also helps to plan and organize appropriate intervention to reduce the symptom burden and thereby improve the quality of life.
Acknowledgment
The authors thank all study participants, the District Medical Officer, Dakshina Kannada and NITTE (Deemed to be University) for making this survey possible.
Funding source: Nil
Ethical approval
The Institutional Ethics Committee of Nitte Usha Institute of Nursing Sciences (Ref: NUINS/CON/ NU/IEC/2016-17) and the Central Ethics Committee of NITTE (Deemed to be University) Deralakatte issued an ethical clearance certificate (Ref: NU/CEC/2018-2018/0143).
Declaration of competing interest
The authors have extensively contributed to the research study from the origin of the study to data collection and writing the report. There is no conflict of interest.
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