Postmenopausal Symptoms and Management by Women in Delhi

Abstract

Menopause is defined as the complete cessation of the menstrual cycle in women for twelve consecutive months. Although menopause is an important aspect of the female reproductive health cycle, it is often ignored. Women may experience different menopausal and postmenopausal symptoms ranging from mild to severe. In the present study, a cross-sectional survey of 200 women in their postmenopausal years was conducted across Delhi and the National Capital Region (NCR). A pretested questionnaire was given to a random population of postmenopausal women to record various postmenopausal symptoms and the coping strategies adopted by them. The mean age of menopause of the sample population was 47.48 years, and body mass index seemed to affect the age of onset of menopause. The majority of women experienced postmenopausal symptoms, with 95.28% experiencing more than one symptom, ranging from fatigue and sleep disturbances to severe symptoms such as anxiety attacks, palpitations and joint pains. Many women used different coping strategies, such as changes in lifestyle and social interaction with other women experiencing menopause. Very few women used hormone replacement therapy as a coping mechanism and most of them were ignorant about the same. Interestingly, both education and working status were observed to affect the adoption of coping strategies by women in Delhi–NCR. The results of the study emphasize the need of addressing the problems of the postmenopausal population and incorporating the same in the national healthcare programme.

Keywords

Postmenopause coping strategies menstruation symptoms climacteric

1. Introduction

Biologically, menopause is a physiological phenomenon as a result of reduced ovarian function and is said to occur following the cessation of menstruation or amenorrhea for a period of twelve months. The onset of menopause is usually preceded by a transitional phase known as perimenopause, an interim period characterized by irregular periods, poor sleep, depressed mood, increased anxiety, hot flashes etc. until complete menopause is attained (Ahuja, 2016; Santoro, 2016). The period of menopause is associated with several physical and mental symptoms such as hot flashes, urogenital symptoms, depression, irritability, sleep disturbances and trouble with concentrating. Menopause can be seen as a natural transition to a new stage of life encompassing not only biological changes associated with the natural ageing process but also social changes that include self-perception and societal perceptions of older women. On an average, a woman spends one third of her life in a postmenopausal phase wherein risks for several health conditions such as diabetes, breast cancer, osteoporosis and cervical cancer increase (Satpathy, 2016).

At the physiological level, during menopause the number of ovarian follicles decreases and as a result the ovary becomes incapable of responding to the follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secreted by the pituitary gland. Ovulation becomes irregular and then slowly terminates; simultaneously, the production of ovarian estrogen and progesterone ceases. In some cases, there is an early loss of ovarian functions, which leads to premature cessation of menstruation. Menopause before the age of 40 is called premature menopause or primary ovarian insufficiency and is commonly attributed to factors such as smoking, nutritional status, family history, chemotherapy or surgery (Jungari & Chauhan, 2017; Koukouliata et al., 2017). While women experiencing premature menopause are at higher risk of developing cardiovascular diseases and osteoporosis, they are also at a reduced risk of breast cancer (Kelsey et al., 1993; Khosla & Riggs, 2005). In India, 1% women below 40 years and 0.1% women below 30 years are affected by premature menopause. Among the women undergoing menopause, 5.5% experience premature menopause and among states, Andhra Pradesh has highest incidences of premature menopause i.e. 14.6% (Jungari & Chauhan, 2017).

Due to better medical and living conditions that have increased life expectancies in India, women can now expect to live more than half of their lives in a hormone-deficient state (Ganapathy & Furaikh, 2018). Along with infertility issues, several symptoms are associated with menopause. In addition, menopausal age serves as a biomarker for disease and mortality. It has been observed that mortality decreases by about 2% while the risk of uterine cancer increases by about 5% with each successive year after menopause (Ossewaarde et al., 2005). Postmenopause-related symptoms have been extensively studied in Western countries (Rezarta et al., 2017; Santoro et al., 2015; Yisma et al., 2017), and it has been observed that some postmenopausal symptoms are severe and affect normal lifestyle of the postmenopausal women. However, little information is available in India about postmenopause-related symptoms and coping strategies (Singh & Pradhan, 2014). In view of this, we undertook a study in Delhi and the National Capital Region (NCR), India, to assess the symptoms experienced by menopausal and postmenopausal women and the strategies adopted by them to cope with these symptoms. We also made an effort to understand whether education, working status and economic status had an impact on the management strategies women adopted to cope with postmenopausal symptoms.

2. Methodology

We undertook a cross-sectional study in Delhi and the NCR between January 2018 and August 2018. A pretested questionnaire was prepared and administered to a random sample. The sample population included 200 postmenopausal women in the age group of 35 to 65 years, the criteria being those who had experienced menopause within five years at the time of the survey and who had no chronic diseases or had not undergone hysterectomies. Menopausal status was classified according to STRAW (Stages of Reproductive Aging Workshop) classification, i.e. menopause/postmenopause: no menstrual bleeding in the previous/last twelve months (Soules et al., 2001). The respondents were assured of total discretion, and their written informed consent was taken after explaining the study procedure to them. The subjects were interviewed in the local language as per their convenience in their households or places of work.

The questionnaire contained three distinct sections:

Demography record: This included information about the age of respondents, their menopausal age, marital status, weight, height, educational qualification, economic status and working status.

Postmenopausal symptoms: To assess postmenopausal symptoms the Menopause Rating Scale (MRS) developed by Heinemann et al. (2003) with modifications was used. Postmenopausal symptoms were classified under three categories, i.e., physical, psychological and urogenital. The physical symptoms included hot flashes, muscle and joint pain, palpitation and sleep problem. Depression, irritability, tiredness, low self- esteem and loss of memory were placed in the psychological section, while increase in frequency of urination was included in urogenital category.

Coping strategies: The means of management of postmenopausal symptoms included changes in lifestyle (diet, exercise, vitamin supplements, calcium intake), social interventions (consulting peers having similar problems), practical changes (double checking work or taking notes, to deal with memory problems), informational (gathering more information about menopause and coping strategies) and hormone replacement therapy (HRT).

An attempt was made to correlate education, economic status and working status of postmenopausal women with the coping strategies adopted by them. The data were analysed and the graphs were prepared using MS Excel.

3. Results

3.1 Demography

The sample population included 200 postmenopausal women from Delhi and NCR in the age group of 35–65 years, the majority (67%) of whom were homemakers. Most of the women came from households with an annual income of less than ₹5 lakhs, while only 12.5% had an annual income of more than ₹10 lakhs. The majority of the sample population (96%) were married women; very few were illiterate (~22%), with the rest having different levels of educational qualification, ranging from secondary, higher secondary, graduate to postgraduate (Table 1).

Table 1.
Socio-demographic Characteristics of the Postmenopausal Sample Population Surveyed in Delhi–NCR (n = 200)

Socio-demographic variable Number (%) Characteristic Number (%)

Age group of post menopausal sample population Job status

36–40 1 (0.5%) Working 66 (33%)

41–45 10 (5%) Homemaker 134 (67%)

46–50 34 (17%) Marital status

51–55 68 (34%) Married 192 (96%)

56–60 58 (29%) Unmarried 8 (4%)

61–65 29 (14.5%)

Economic status (household income per annum in INR) Educational qualification

Less than 1 lakh 60 (30%) Illiterate 45 (22.5%)

1–5 lakh 71 (35.5%) Secondary/higher secondary 85 (42.5%)

5–10 lakh 44 (22%) Graduate/postgraduate 70 ( 35%)

More than 10 lakh 25 (12.5%)

Socio-demographic variable	Number (%)	Characteristic	Number (%)
Age group of post menopausal sample population	Job status
36–40	1 (0.5%)	Working	66 (33%)
41–45	10 (5%)	Homemaker	134 (67%)
46–50	34 (17%)	Marital status
51–55	68 (34%)	Married	192 (96%)
56–60	58 (29%)	Unmarried	8 (4%)
61–65	29 (14.5%)
Economic status (household income per annum in INR)	Educational qualification
Less than 1 lakh	60 (30%)	Illiterate	45 (22.5%)
1–5 lakh	71 (35.5%)	Secondary/higher secondary	85 (42.5%)
5–10 lakh	44 (22%)	Graduate/postgraduate	70 ( 35%)
More than 10 lakh	25 (12.5%)

Source: The authors.

The majority of women (31%) surveyed underwent menopause in the age group of 46–50 years, with the average age of menopause being 47.48 years (Figure 1). A small number of women had experienced premature menopause between the ages of 31–35 years (3%) and 36–40 years (7.5%) while some women (6.5%) had very late menopause, at the age of 56–60 years. Among obese women, maximum percentage (39.13%) attained menopause during 51–55 years (Figure 2). The mean age of menopause of women with normal weight was 46.64 years, whereas it was 47.79 years and 48 years for overweight and obese women respectively.

Figure 1.

Source: The authors.

Figure 2.

Source: The authors.

3.2 Postmenopausal Symptoms

In the sample population surveyed, 95.50% of the women experienced some form of postmenopausal symptoms, while only 4.5% did not experience any such symptoms. The most common postmenopausal symptoms experienced (Table 2) were fatigue (80.42%), joint and muscle aches (74.07%), sleep disturbances (63.49%) and mood swings (61.90%), all of which affected the general life of 52.36% (n = 191) women and work life of 52.38% women (n = 63).

Table 2.
Postmenopausal Symptoms Experienced by Women in Delhi–NCR (n = 191)

No. Menopausal Symptoms Percentage of Women Experiencing the Symptom

1. Physical Weight gain 56.08

Joint and muscle aches 74.07

Tiredness 80.42

Hot flushes 47.09

Sleep disturbance 63.49

Irregular heartbeat/palpitation 57.67

Changes in skin/skin dryness 51.32

2. Psychological Tearfullness 32.28

Irritability 58.20

Poor memory 53.97

Poor concentration 49.74

Mood swings 61.90

Anxiety/panic attacks 53.97

Feeling low/depressed 51.32

Lowered confidence 36.51

Clumsiness 20.11

3. Urogenital Frequent urination 50.79

No.	Menopausal Symptoms	Percentage of Women Experiencing the Symptom
1.	Physical	Weight gain	56.08
		Joint and muscle aches	74.07
		Tiredness	80.42
		Hot flushes	47.09
		Sleep disturbance	63.49
		Irregular heartbeat/palpitation	57.67
		Changes in skin/skin dryness	51.32
2.	Psychological	Tearfullness	32.28
	Irritability	58.20
	Poor memory	53.97
	Poor concentration	49.74
	Mood swings	61.90
		Anxiety/panic attacks	53.97
		Feeling low/depressed	51.32
		Lowered confidence	36.51
		Clumsiness	20.11
3.	Urogenital	Frequent urination	50.79

Source: The authors.

3.3 Management of Postmenopausal Symptoms and Correlation of Coping Strategies with Educational Background, Working Status and Economic Status

In order to combat the debilitating symptoms associated with menopause, 51.31% of women adopted some means of coping strategy, while 48.69% did not adopt any such strategy. The most common coping strategy adopted was change in lifestyle (66.33%), such as inclusion of exercise in their daily routine or changes in diet, followed by social interaction with peers (43.88%), gathering information about menopause from various sources such as social media, newspapers and magazines (29.59%), hormone replacement therapy (4.08%) and making notes to deal with memory loss and confusion (3.06%).

There was a direct correlation of the adoption of coping strategy with the educational status of the women. A total of 74.29% of women who were highly educated, including postgraduates and above, were more aware and adopted some means of coping strategies, whereas among women who had secondary school education and higher secondary education, only 39.22% and 47.06%, respectively, adopted coping strategies to manage their postmenopausal symptoms (Figure 3). Working women were found to be more inclined (60.66%) towards management of postmenopausal symptoms using various strategies when compared to homemakers (46.87%). Interestingly, no direct correlation could be observed between economic status and adoption of coping strategies.

Figure 3.

Source: The authors.

4. Discussion

Though the age of menopause has been linked with several factors, such as smoking, marital status, family history, diet, employment status, abortion and body mass index (BMI), but there is no clear association between these factors and menopause (Pallikadavath et al., 2016). Worldwide, studies have revealed that distribution of menopausal age displays a bell-shaped curve that ranges from 40 to 54 years (Ceylan & Özerdoǧan, 2015). The average age of menopause in Indian women has been reported as 46.2 years in a pan India study conducted by Ahuja (2016), which closely correlates with the average menopause age of 47.48 years found in women of Delhi and NCR. We found that 10.5% women experienced early menopause, i.e. before the age of 40 years, which might be due to premature ovarian failure or other causes which damage ovaries, while a few women experienced late menopause after the age of 55 years. The median age of menopause in Europe ranges from 50.1 to 52.8 years, in North America from 50.5 to 51.4 years, in Latin America from 43.8 to 53 years and in Asia from 42.1 to 49.5 years (Palacios et al., 2010). The significance of the early age of menopause in Asian women including Indian women is that it predisposes them to health disorders almost a decade earlier than their Caucasian counterparts. Many factors affect the age of onset of menopause, such as age of menarche, genetic factors, socio-economic factors, use of oral contraceptives, BMI etc. (Ceylan & Özerdoǧan, 2015). In addition to these factors, the onset of menopause is also affected by geographical regions as asserted by Palacios et al. (2010). In our study, BMI was seen to affect menopausal age as it was observed that in overweight and obese women, the mean age of menopause was later than in women with normal weight. Also, a significantly large percentage of overweight women had late menopause, at the age of 56–60 years. This observation correlates with an earlier study by Zhu et al. (2018), in which it was reported that overweight and obese women experience late menopause.

Menopause may cause drastic changes in a female’s body, and studies have shown that women experience physical, psychosocial and sexual changes during the postmenopausal period that affects their quality of life (Ceylan & Özerdoǧan, 2015). Apart from this, social expectations, marital status, religious beliefs, cultural roles and employment status also play an important role in the quality of life of postmenopausal women (Heidari et al., 2019). However, the intensity of the symptoms varies from individual to individual, although the frequency of a symptom in one individual may remain constant (Utian, 2005). In the present study, we report that fatigue followed by joint and muscle ache and sleep disturbance are the three most common postmenopausal symptoms experienced by women in Delhi–NCR. Backaches, muscle pain, shoulder pain or joint pain are predominant symptoms reported in postmenopausal Asian women, unlike vasomotor disturbances experienced by women in Western countries (Chim et al., 2002; Haines et al., 2005; Ho et al., 2003; Lam et al., 2003). However, the prevalence of individual menopausal symptoms varied even among the 11 sub-ethnic groups of Asian women as observed by Haines et al. (2005). These symptoms are attributed to estrogen deficiency as it has been observed that estrogen replacement helps to combat these issues (Dalal & Agarwal, 2015). However, increased level of FSH, decreased level of Inhibin B (Al-Safi & Santoro, 2014) and activation of 5-hydroxytryptamine receptor (Santoro et al., 2015) also contribute to the occurrence of various postmenopausal symptoms.

Our study’s findings suggest that while postmenopausal symptoms affected the work life and life in general of a large percentage of women, overall they appear to experience a reduced intensity of symptoms compared to women from Africa and America (Al-Safi & Santoro, 2014). This might be because of the prevalence of vegetarian diets which include soy products which are rich in phytoestrogens, as suggested by a study of phytoestrogen supplements that points to the reduced frequency or severity of postmenopausal symptoms in women (Lethaby, et al. 2013).

To combat postmenopausal symptoms, women adopted different means to maintain their comfort levels. A large percentage of women in Delhi–NCR made changes in their lifestyles, including changes in food habits, including exercise in their daily routines or taking calcium and vitamin supplements to cope with the changes they experienced. In previous studies by Teoman et al. (2004) and Meeta et al. (2013), exercise and change in diet have been reported to play important roles in management of postmenopausal symptoms. In our survey, only a marginal population adopted HRT as a coping strategy and very few women had heard about HRT. This observation is in contrast to women in Europe, where almost 52% women studied in a survey were aware of HRT and almost 40% had used it at some point or other to cope with postmenopausal symptoms (Genazzani et al., 2006). One of the reasons for the decreased use of HRT may be its high cost (Utian, 2005). Also, the increased risk of heart disease, stroke, invasive breast cancer and venous thromboembolism with HRT (Humphries & Gill, 2003) might act as deterrent for many. In recent years, yoga is being explored as a means of managing postmenopausal symptoms as it has been evidenced that yoga practice is effective in relieving many climacteric symptoms (Vaze & Joshi, 2010).

An interesting aspect of our study was the correlation of education and working status of women with management of postmenopausal symptoms. It was observed that coping strategies were usually adopted by working women with higher education. This was not surprising though, because educational intervention has been stated as an effective means to enable women to manage postmenopausal symptoms (Lim, 2013). Also, working women get an increased opportunity to interact with other women at their work place, thereby giving them an opportunity to explore management strategies. However, we found that the economic status had no role to play in women trying to alleviate climacteric symptoms. This might be due to the fact that mostly the coping strategies adopted by women in Delhi–NCR were not dependent on money. Rather, anyone aware about the management strategies such as exercise and change in lifestyle can easily adopt them.

5. Conclusion

Menopause not only marks the end of reproductive function but also introduces women to a new phase of life. Classical symptoms of menopause may interfere with physical and mental wellbeing and quality of life. Many of these symptoms can be prevented and/or reduced by timely intervention of lifestyle modifications such as exercise, changes in food habits and supplementations such as calcium, vitamin D and micronutrients. In India, currently there are few healthcare programmes that cater to the post-reproductive health needs of women. Different programmes are initiated for reproductive age group, ignoring post-reproductive age group. As a result, a majority of the women are tolerating postmenopausal health burden in silence. This makes it very important to assess how women adapt to or suffer due to menopausal symptoms, which may provide information that may guide policy formation and enlighten clinicians to pay more attention to postmenopausal women’s plight. Specialized menopausal clinics similar to antenatal clinics are need of the hour and should be initiated by the government and nongovernment organizations.

6. Limitations

The participants of the present study were asked some questions, such as age of menopause, which they answered based on their memory and, hence, recall bias was inevitable. Also, the population did not have an equal representation of married and unmarried women, and hence no conclusion could be drawn as to relation of marital status and age of menopause. Further, the BMI represented the status of women during interview and not at the time of actual age of menopause. Hence, the concrete correlation between BMI and age of menopause might not be represented. Another limitation was that natural ageing process may also interfere with the perception and/or experience of postmenopausal symptoms. The hesitation of women to speak about genital problems associated with menopause such as vaginal dryness and libido also limits the conclusions of this study.

Footnotes

Acknowledgements

The authors are indebted to Principal, Maitreyi College, Chanakyapuri, New Delhi, for her constant encouragement and support.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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Postmenopausal Symptoms and Management by Women in Delhi–NCR

Abstract

Keywords

1. Introduction

2. Methodology

3. Results

3.1 Demography

5. Conclusion

6. Limitations

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

References