|
Note: Tables of the article can be accessed and seen in the PDF file.
Introduction
Modern medicine has significantly
increased the life expectancy of women throughout the
world.1 The world population of women aged
over 60 years was below 250 millions in 1960 and it is
estimated that in 2030 1.2 billion women will be peri or
postmenopausal and this will increase by 4.7 millions a
year.2
Menopause is a physiological event in the women’s life.
It is caused by aging of ovaries which leads to decline
in the production of ovarian Gonadotrophins Estrogen and
Progesterone. The deficiency of these hormones elicits
various somatic, vasomotor, sexual and psychological
symptoms that impair the overall quality of life of
women.3-4
Given the rise in the life expectancy the woman can now
expect to live approximately one third of her life in
hormone deficient state with impaired quality of life (QoL),
the study on QOL in menopausal women thus becomes an
essential component in clinical practice.5
It has been reported that the experience of menopausal
symptoms involves not only a complex interaction between
sociocultural, psychological and environmental factors
but also the biological changes related to the altered
ovarian hormonal status or deficiency.3,6
The nature, frequency and severity of symptoms vary not
only among the individuals of the same population with
different cultures, ethnicities and women from different
countries, 6 but also at different stages of
menopause. Several studies reported the experiences of
menopausal symptoms of women from different parts of
world and the significant impact of these symptoms on
QoL of menopausal women at different status of
menopause.7, 8
The World Health Organization defines QoL as an
individual’s perception of their position in life in the
context of the culture and value system in which they
live and in relation to their goals, expectations,
standards and concerns. 9
Host of studies have been conducted to measure the QoL
of menopausal women from western world 10-12
with different sociocultural realities which may
influence not only the perception of QoL but also the
experience of menopause at different status of
menopause. Very little information exists about QoL of
menopausal women in developing countries.13,
14
The
present study is very important as to the best of our
knowledge this is the first community based research
conducted in rural areas of Sindh. The objective of
following research was to investigate the severity of
menopausal symptoms associated with menopausal status
and to determine the quality of life of menopausal women
from rural Sindh Pakistan.
Methods
Study Setting:
This
population based survey was conducted in one of rural
district of Sindh Province Pakistan from November 2007
to October 2008.
Matiary is one of the rural District of Sindh located on
the highway comprises of 3 Talika and 19 Union Councils,
which are the administrative units defined by National
reconstructive Bureau (NRB) Government of Pakistan. The
total population of the district is 5, 25,082 living in
56,053 households in the 1509 villages. The majority of
peoples are Sindhi speaking Muslims, able to understand
the National language (Urdu).15
Design:
A multistage
stratified random sampling technique was used for the
identification of eligible women. At first stage of
sampling 10 union councils from all 3 Talika was
selected using lottery method. During the second stage
of sampling the name and address list of all the women
aged 40 – 70 years was drawn from the Basic Health
Centers record (KHANDAN) register which is one of the
Health Management and Information System (HMIS) Tools of
National Programm for Family Planning and Primary Health
Care Pakistan. The total 15721 women’s names and
addresses were retrieved. In the third stage, out of
established list every fourth women was selected
randomly. Initially for the selection of first number
the lottery method was used for the first four numbers
followed by every fourth number onward included into
sample. The net sample (without migrated and deceased
women) comprised of 3929 women.
Staff and Instruments
Staff:
We have
selected 5 teams of interviewers each comprised of 3
members two Lady Health Workers and one Lady Health
supervisor of National Programm of Family Planning and
Primary health Care Matiary Pakistan.
The
National Programm of Family Planning and Primary health
Care Pakistan is one of the ongoing success stories of
health sector in Pakistan. With 100,000 Community based
health workers it provides the health care to 30 million
peoples in Pakistan. In Matiary district the lady health
workers are working efficiently and providing health
care to 65% of total population of the district. Each
lady health worker provides services to 1000 population
and they maintain the HMIS tools including KHANDAN
registers.
Each
team for the present study was allocated the 2 union
councils for the survey. The Lady Health worker (LHW)
were directed to conduct interview and lady health
supervisor (LHS) was directed to supervise them. The
training of data collectors for delivering the
questionnaire was done by the researchers and followed
by field testing of the questionnaire.
Instruments:
The questionnaire for
present research comprises of three sections. Section I
pertains information regarding demography (like age,
education, employment and marital status) and
reproductive parameters (such as parity, age at
menarche, regularity of menses, years since last
menstruation). The socioeconomic status of participants
was categorized according to the working status of
husband/ brother or son in cases of unmarried or widow
participants. The three groups were categorized as, the
non working, laborer and farmers who find it hard to pay
for their basic amenities were grouped in the category
of poor, those who were working as a government employee
or having small business can easily pay for their
basic amenities but strive hard to enjoy luxuries ware
considered in the category of middle class and those who
were landlord or upper rank government servant who can
enjoy luxuries were classified as upper class. Section
II assessed the menopausal symptoms for which Menopause
Rating scale (MRS) was used and the section III was
related to the assessment of health related quality of
life (HRQOL). The WHOQoL Brief questionnaire in Urdu
Version was used for it.
Menopause Rating Scale:
It comprises of 11 items assessing menopausal symptoms,
divided into three subscales. A) Somatic: Hot flushes,
heart discomfort, sleep problem and muscles and joint
problems. B) Psychological: depression, irritability,
anxiety and physical and mental exhaustion. C)
Urogenital: Sexual problems, bladder problems and
dryness of vagina. Each item can be graded from 0-4, (0=
not present), (1=mild), (2=moderate), (3=severe),
(4=very severe).16 For the present study the
MRS English version 17 was translated into
local language.
WHOQOL Brief:
WHOQOL
questionnaire has been developed in order to make a
reliable, valid and responsive assessment of generic QOL
that is applicable to the people living in
different conditions and cultures. Two versions are
available the WHOQOL with 100 items and 26 items short
form version of WhOQOL 100.18,19 We have used
WHOQOL Brief (Urdu Version) for its brevity. The Urdu
version is has been available with excellent reliability
and validity.20
The
WHOQOL Brief consists of four domains Physical,
Psychological, Social and Environmental. The scores were
calculated according to the standard methods that the
raw scores were converted to transformation scores. The
first transformation converts scores to range of 4-20
and the second transformation converts domain scores to
0-100 scale. Higher scores reflect better quality of
life.
Menopause status definition:
The
menopause status was defined based on the reported
length of time since last menstrual period. Women who
reported the normal menstrual cycle for last three
months were classified as Premenopause. Women who
reported change in the length of menstrual cycle for at
least seven days from baseline or change in the
menstrual flow like lighter or heavier from baseline for
last three months were classified perimenopause, those
last menstrual periods occurred 12 months or more months
ago were categorized as post menopause. Surgical
menopause was defined as cessation of menstruation
following either removal of ovaries (with or without
hysterectomy).21
Statistical analysis:
Statistical
package for social sciences (SPSS) version 15.0 was used
for data analysis. Results are presented as numbers
(percentages) for qualitative variables and mean ±
standard deviation for normally distributed quantitative
variables are reported. Differences in proportion for
menopausal status, demographic and health
characteristics were assessed by Pearson Chi-square test
and difference in mean score for quality of life were
compared using analysis of variance or Kruska Wallis
test for skewed data. Pearson coefficient of correlation
(r) was determined among WHOQOL and MRS score. P-value
less than 0.05 was considered as statistical significant
Ethical Consideration:
Both
written and oral information about the reasons of the
study were given in local language to women invited to
participate in the present study. The participants were
informed that their inclusion in the study will be
voluntary and were given a guarantee of anonymity. They
were informed that they were free to withdraw from study
and if any question they do not want to answer they can
withdraw it.
The
executive district officer for National Programm for
family planning and Primary health care Matiary district
provided permission under reference (NO: EDO(H) Matiari/E-1/-7256/57
) to conduct the present study.
Results
During the study period
total 3929 women were approached to participate. Out of
it 167(4.2%) were migrated / not available at their
addresses. 318(8.0%) has refused to participate in the
survey. 382(9.7%) were excluded because of incomplete
questionnaires. The net sample comprises of 3062 women.
The mean age of entire sample was 49.38±7.20 (median 48)
and range was 40-70 year.
Half of
the women were aged 41-60 years. The proportion of women
who receive no formal education was 2611(85.3%), only
39(1.3%) of them having 12 years or >12yeras of
education.
Most of
women 3037 (99.1%) were married, house wives 2316
(75.6%) and living with husband 2354 (76.9%).
Majority of the study population 1979 (64.6%) belongs to
poor socioeconomic status, while only 176(5.7%) were
from upper class. The mean parity was 6.65±3.39 with
range 0-20.
Regarding the menopausal status of whole population
surveyed the post menopause was reported by 1478(49.1%)
of women, the pre and peri menopausal status was
reported by 641(21.3%) and 892(29.6%) respectively,
while 51(1.6%) women did were not sure about their
menopausal status. As shown in table I.
Table
II shows the distribution of symptoms contained in MRS
presented as percentages and mean scores in relation to
menopausal status.
The
percentages for somatic, psychological and urogenital
symptoms were significantly high in women at peri and
postmenopausal status, while the symptom experience of
Premenopausal women is lower than peri and
postmenopausal women.
The
total MRS score was found significantly high in peri and
postmenopausal women (15.2±7.3) and (14.4±7.8) P< 0.001
in comparison of Premenopausal women (11.9 ±6.5).
The
WHOQOL Brief scores for different menopausal status were
presented in table III.
We have
found significantly lower scores in physical,
psychological and somatic domains for Post menopausal
women as compared to pre and perimenopausal group(P= <
0.001).
The
correlation between MRS scores and WHOQOL- Brief scores
is shown in table IV. In the Pre and perimenopause group
only one, the physical domain was found to be
significantly associated with MRS scores while the
negative correlation between MRS scores and WHOQOL-
Brief scores in all domains was found for postmenopausal
women.
Discussion
So far, to the best
of our knowledge, this is the first kind of study
conducted in rural area of Sindh to assess the severity
of menopausal symptoms and quality of life of menopausal
women.
The present study indicated an overall increase
prevalence of menopausal symptoms in studied population
than those found in literature.22-26
The
reasons for different frequencies can be many as the
menopausal symptoms are influenced by sociodemographic/sociocultural
factors, economical stresses, general health status,
individual perception of menopause, genetic and racial
differences and reproductive parameters like parity.
Apart from all these differences the different design of
studies, sample size, age range, distribution of
menopausal status of participants and the instruments
used may also account for discrepant findings.
In present study we have used MRS for the scoring
symptom, which is validated instrument16 Schneider et al
evaluated the MRS for evaluation of menopausal symptoms
by comparison with other instruments relevant for women
in menopausal transition. It was found that there was a
high association of raw scores between Kuppermen index,
Sf-36 and the MRS.27
The present study indicated significant increase in
percent occurrence of Somatic, Psychological and
Urogenital symptoms from Premenopausal to perimenopausal
status, while the symptoms either decline or remain
stable in the postmenopausal women, similar findings
were reported in literature.14,
28
This
may correlates with fluctuating levels of estrogen in
the blood from Premenopause to Peri and postmenopausal
period.
Like
present study several other studies from literature
reported that physical and psychological symptoms were
highly significant in Asian women. 14,24, 29,30,31
The different cross sectional surveys conducted on
different population including women from England,
Holland, Taiwan, Chili, France, Sudan, Japan, china and
Africa showed that perimenopausal women reported great
bodily pain and role limitation due to physical health
and environmental problems.32,33
The data for present study showed that the mean scores
of MRS were significantly high for Somatic and
Psychological symptoms in Peri and Postmenopausal women
these findings were consistent with several other
studies.34
It may
be due to the fact that most of our studied subjects
were from poor, less educated and with high parity. The
poor women having fewer intakes of healthy and caloric
diet, poor awareness and excess to health facility and
excessive physical work to take care of family and
concerns regarding the needs of growing children may be
the reasons for the high MRS scores for physical and
Psychological domain.
Another
aspect of worth mentioning is the fact that the
urogenital symptoms including sexual problems, bladder
problems and dryness of vagina were less frequent; the
individual and overall scores of MRS were also low for
urogenital domain.
The
possible explanation to it may be that the
postmenopausal women are less active sexually in our
rural society 35 they become involved in
taking care of their grand children and in performing
religious activities like offering prayers and other
rituals.
We have found significant difference in the mean scores
of the domain (Physical, Psychological, Social) and the
total scores of WHOQOL- Brief at different menopausal
status, these findings were inconsistent with other
reports from the literature
14, 36, 37
This
may be due to the high scores of MRS for different
menopausal symptoms. We did not found significant
difference in scores for environmental domain of WHOQOL-
Brief. The environmental domain access the influences on
the QOL of factors like financial resources, the work
environment, access to health and social care, freedom,
security.
These
may not play a major role in detecting health status at
different menopausal status.
The correlation between MRS scores and WHOQOL- Brief
scores indicated that there was a significant difference
between the Premenopause, Perimenopause and post
menopause group. In the Premenopause and perimenopause
group only one, the physical domain was found to be
significantly associated with MRS scores on the other
hand there was a negative correlation between MRS scores
and WHOQOL- Brief scores in all domains for
postmenopausal women.14
In
present study we have found that the magnitude of
menopausal symptoms on MRS were almost similar for Peri
and postmenopausal women but the WHOQOL-Brief scores for
all domain were significantly lower for postmenopausal
women, it indicates that not only the menopausal
symptoms but aging, increasing frequency of chronic
illness and social deprivation may have negative impact
on QOL of menopausal women. This requires further
studies in the relation to the impact of menopausal
symptoms at various age groups.
There
are several limitations with the present study. First
the women were asked to provide some retrospective
information such as climacteric symptoms experienced in
preceding weeks, regularity of menses and last menstrual
period hence the recall bias is unavoidable especially
in some older women. The lack of correct information on
regularity of menses the some subjects could have been
misclassified in Peri and Premenopausal status Second
the seasonal onset of some menopausal symptoms like
sweating might be a confounding factor as the weather of
the region is hot and women may not distinguish between
the sensations of heat and sweating caused by hot
weather. Third this was a cross sectional survey, for
determination of relation between case and effect of
menopausal symptoms and QOL requires the longitudinal
cohort studies to be conducted. Further investigations
will be expected in more extensive geographic areas with
larger population in Pakistan.
Strengths of present study are the population based
character and the use of validated instruments to assess
Menopausal symptoms and QOL.
Conclusion
The rural women from Sindh
Province Pakistan at various menopausal status
experience high prevalence of menopausal symptoms. The
high percentage and the Scores of MRS were observed in
perimenopausal and postmenopausal women. The severity of
symptoms was found more distressing for postmenopausal
women then for women at other status of menopause. The
QOL of postmenopausal rural women was decreased due to
severity of menopausal symptoms.
Funding:
The present study is
not funded by any Governmental or Non Governmental
organization.
Conflict of Interest:
Nil
Acknowledgment:
The authors wish to
express thanks to the Mr. Murad Ali Shah, Executive
District Officer for National Program for family
planning and primary health care District Matiary for
providing Permission for this survey. They also wish to
thanks the lady health workers and supervisors for
National Program for family planning and primary health
care for their hard work and dedication in collection of
data. The helpful discussion on statistical analysis of
MR Mohammad Islam Senior Instructor Department Community
Health sciences Agha Khan University Karachi is highly
acknowledged.
References
1. Cheng
MH, Wang S, Wang P, Fuh J. Attitude towards menopause
among middle aged women: a community survey in an Island
of Taiwan. Maturitas 2005;52(3): 348-355.
2.
Jin YL, Chang SS.
The attitude of postmenopausal women towards hormone
replacement therapy (HRT) and effects of HRT on Lipid
profiles. Proceedings of the first consensus meeting on
menopause in East Asian region, 1997;may 26-30, Geneva,
Switzerland. Available at:
http://www.gfmer.ch/books/bookmp/7.3.htm.
3.
Dennerstein L,
Dudly EC, Hopper JL, Guthrie, Burger HG. A prospective
population-based study of menopausal symptoms. Obstet
Gynecol 2000; 96: 351-8.
4.
Deeks AA, McCabe
MP. Well being and menopause: an investigation of
purpose in life, self acceptance and social role in
pre-menopausal, peri menopausal and postmenopausal
women. Qual Life Res 2004; 13: 389-98.
5.
Genazzani AR,
Nicolucci A, Campagnoli C, Crosgnani P, Nappi C, Serra
GB, Bottiglioni E, Cianci A, De Aloysio D, Donati Sarti
C et al. Assessment of QoL in Italian menopausal women
comparison between HRT users and Non users. Maturitas
2002; 42: 267-280.
6.
Randolph JF Jr,
Sowers M, Gold EB, Mohr BA, Luborshy J, Santoro N.
Reproductive hormones in early menopausal transition:
relationship to ethinicity, body size and menopausal
status. J clin Endocrinol Metab 2003; 88: 1516-22.
7.
Blumel JE,
Catelo-Bramco C, Binfa L, Gramegna G, Tacla X, Aracena
B, Cumsille MA, Sanjuan A. Quality of life after
menopause: A population study. Mturitas 2000; 34(1):
17-23.
8.
Fuh JL, Wang SJ,
Lee SR, Lu SR, Juang KD. Quality of life and menopausal
transition for middle aged women on Kinmen Island. Qual
Life Res 2003; 22: 53-61.
9.
WHOQOL Group. Study
protocol for the World Health Organization project to
develop a quality of life assessment instrument
(WHOQOL). Qual Life Res 1993; 2: 153-159.
10.
Chedrani P, Blumel
J, Baron G, Belzares E, Bencosme A, Calle A, Danckers L,
Espinoza MT, Flores D et al. Impaired quality of life
among middle aged women: A multicentre Latin American
study. Maturitas 2008; 61: 323-329.
11.
Schwarz S, Volzke
H, Atte D, Schwahu C, grabe HJ, Hoffmann W, Doren M.
Menopause and determinants of quality of life in women
at midle life and beyond: The study of health in
Pomerania (SHIP). Menopause 2007; 14: 123-133.
12.
Conde DM,
Pinto-Neto AM, Santos-sa D, Coste- Paiva L, Martinez EZ.
Factors associated with quality of life in a cohort of
postmenopausal women. Gynecological Endocrinology 2006;
22(8): 441-446.
13.
Lai JN, Chen HJ,
Chen CM, Chen PC, Wang JD. Quality of life and
climacteric complaints amongst women seeking medical
advice in Taiwan: assessment using WHOQOL- Breif
Questionnaire. Climacteric 2006; 9: 119-128.
14.
Santoh T, Ohashi K.
Quality of life assessment in community- dwelling middle
aged healthy women in Japan. Climacteric 2005; 8:
146-153.
15.
en.wikipedia.org/wiki/Matiari_District
16.
Heinemenn LA, Pottoff P, Schneider HP.
International version of the menopausal rating scale
(MRS). Health Qual Life Outcomes 2003; 1: 28.
17.
http://www.biomedcentral.com/content/supplementary/1477-7525-1-28-53.pdf
18.
WHOQOL Group:
Development of the WHOQOL: rational and current status
.Int J Mental Health 1994; 23: 24-56.
19.
Skevington SM,
Lofty M, O’Connell KA. WHOQOL Group. The World Health
Organization’s WHOQOL- Breif quality of life assessment:
psychometric properties and results of the international
field trial. A report from WHOQOL group. Qual Life Re
2004; 13:299-310.
20.
Khan MNS, Akhter
MS, Ayub M, Alam S. Translation and validation of life
scale, the brief version. J coll Physicians Surg Pak
2003; 13(2): 98-100.
21.
Soules MR, Sherman
S, Parrott E, Rebar R, Santoro N, Utian N, Woods N.
Executive summary: Stages of Reproductive Aging Workshop
(STAW). Climacteric 2001;4: 267-72.
22.
Qazi RA Age,
Pattern of menopause, climacteric symptoms and
associated problem among urban population of Hyderabad
Pakistan. J Coll Physicians Surg Pak 2006; 16(11):
700-703.
23.
Nisar N, Sohoo NA.
Frequency of menopausal symptoms and their impact on the
quality of life of women: a hospital based survey. J Pak
Med Association 2009; 59(11); 752-756.
24.
Bairy L, Adiga s,
Bhat P, Bhat R. Prevalence of menopausal symptoms and
quality of life after menopause in women from South
India. ANZJOG 2009; 49: 106-109.
25.
Sowers M, Crawford
SL, Sternfeld B, Morganstein D, Gold EB, Greendale GA et
al. SWAN: A multicentre, multi ethenic community based
cohort study of women and the menopausal transition. In:
Lobo and Marcus R, Kelly J. ed. Menopause: biology and
path biology. New York/San Diego: Academic Press: 2000,
175-88.
26.
Gold EB, Block G,
Crawford S, Lachance L, FitzGerald G, Miracle H, et al.
Life style and demographic factors in relation to
vasomotor symptoms: baseline results from the study of
women’s health across the nations. Am J Epidemol 2004;
159: 1189- 99.
27.
Schneider HPG,
Heinemann LAJ, Roseeier HP, Potthoff P, Behre HM. The
menopause rating scale (MRS): Reliability of scores of
menopausal complaints. Climacteric 2003; 3: 59-64.
28.
Kapur P, Sinha B, Perveira BMJ. Measuring climacteric
symptoms and age at natural menopause in an Indian
population using
the Green Climacteric Scale. Menopause 2009; 16(2):
378-384.
29.
Anderson D,
Yoshizawa T, Gollschewski S, Atogami F, Courtney M.
Menopause in Australia and Japan: Effects of country of
residence on menopausal status and menopausal symptoms.
Climacteric 2004; 7: 165-174.
30.
Sievect LL, goodle-Null
SK. Musculoskeletal pain among women of menopausal age
in Pueble, Mexico. J Cross Cult Gerntol 2005; 20:
127-140.
31.
Durgan SA, Powell
LH, Kravitz HM, everson Rose SA, Karavolos K, Lubosky J.
Musculoskeletal pain and menopausal status. Clin J pain
2006; 22: 325-331.
32.
Avis NE, Ory M,
Matthews KA, Schocken M, Bromberger J, Colvin A. Health
related quality of life in a multiethnic sample of
middle aged women. Med care 2003;41: 1262-1276.
33.
Monterrosa A,
Blumel JE, Chedrani P. Increased menopausal symptoms
among Afro- Colombian women as assessed with menopause
rating scale. Maturitas 2008; 59: 182-190.
34.
Avis NE, Assmann
SF, Kravitz HM, Ganz PA, Ory M. Quality of life in
diverse groups of midlife women: assessing the
influences of menopause, health status and psychosocial
and demographic factors. Qual Life Res 2004; 13:
933-946.
35.
Nisar N, Zehra N,
Haider G, Munir AA, Naeem A. Knowledge, attitude and
experience of menopause. JAMC 2008;20(1): 56-59.
36.
Ozkan S, Alatas ES,
Zencir M. Women’s quality of life in premenopausa and
postmenopausal periods. Qual Life Res 2005; 14:
1795-1801. |
