Quality of life of postmenopausal women in rural area,Nepal

Abstract

Background

Menopause is one of the natural phenomena in every woman’s life. The transition phase gradually brings lots of changes in the life of women, both physically and mentally. In Nepal, these changes are often viewed as the symptoms of old age. This study aims to determine the prevalence of menopausal symptoms and their quality of life (QOL).

Methods

A descriptive cross-sectional study was conducted in a rural municipality of Jhapa district, Nepal, with study samples of 215 collected using purposive sampling technique. Semistructured questionnaire and MENQOL questionnaire were used for data collection. Descriptive (mean, standard deviation, frequency and percentage) and inferential statistics (t-test and ANOVA test) were used for data analysis. The confidence interval was taken as 95% and probability of significance at p < 0.05.

Results

The study showed that the mean age of the respondents was 53.51 ± 4.42 years with the mean age at menopause being 47.18 ± 6.16 years. The most prevalent symptoms among postmenopausal women were feeling tired or worn out (98.8%), followed by decrease in stamina (94%), decrease in physical strength (91.2%) and lack of energy (90%). The highest mean score was seen in physical domain (2.88 ± 1.61) followed by sexual (2.77 ± 1.93), vasomotor (2.65 ± 1.84) and psychosocial (2.45 ± 1.55). The overall mean score of QOL was found to be 80.06 ± 24.52. Marital status, number of children, educational status, occupational status and health seeking behaviour had significant association with the QOL score.

Conclusion

The most common symptoms experienced by the postmenopausal women were the physical symptoms followed by sexual, vasomotor and psychosocial. Presence of these symptoms certainly affects the QOL. Hence, effective awareness and education programme regarding the symptoms and ways to minimize those symptoms should be planned and provided both at individual and community levels.

Keywords

Nepal postmenopause quality rural

Background

The life expectancy of humans has been increased due to the new developments in medical sciences.¹ Today women can spend over one-third of their lives in the postmenopausal period.²

Menopause is accompanied by biological and psychological changes that affect women's health and sense of well-being. The physiological, emotional and psychological changes may leave women vulnerable in total and reduce the quality of life (QOL).³

One of the goals of health services for all of the people in the 21st century is to improve the QOL.² QOL tends to decline in midlife women, and there is a need to determine what role, if any, symptoms commonly associated with the transition to menopause and early postmenopausal play in this phenomenon.^4,5

Understanding the impact of menopause on the QOL is a critically important part of the care of symptomatic postmenopausal women.^6,7 Through measuring QOL, we can obtain a more realistic portrayal of individuals' emotions and areas of difficulty in understanding their needs and distribution of health care.⁸ So with this background, the current study aimed to:

Assess the prevalence of menopausal symptoms and QOL of postmenopausal women.

Determine the association of the QOL of postmenopausal women with the selected sociodemographic variables.

Methods

A descriptive cross-sectional study design was used in the study. The study was conducted in a rural municipality of Jhapa district of Nepal over a time period of 5 months from July to November 2020. The study population consisted of all postmenopausal women between the age of 45 and 60 years and has attained menopause for at least 12 consecutive months. Required sample size was calculated using Cochran’s formula. A total of 215 postmenopausal women were selected using purposive sampling technique. Postmenopausal women who could understand Nepali language and willing to participate in the study were included in the study whereas postmenopausal women who were known case of diabetes, hypertension, cardiac disease, thyroid disorders, receiving any kind of hormonal therapy and undergone hysterectomy were excluded.

Instrument

Semistructured questionnaire was developed to collect the sociodemographic variable information and a standard tool (MENQOL-Menopause specific quality of life) was used to assess the QOL of post-menopausal women. The research instrument consisted of two parts: Part 1 (questions related to sociodemographic variables such as age, no. of children, religion, occupation, family income, education, marital status, age at menarche, age at menopause, health seeking behaviour) and Part 2 (MENQOL developed by Lewis JE, Hilditch JR). The MENQOL is self-administered and consists of a total of 29 items in a Likert-scale format. Each item assesses the impact of one of four domains of menopausal symptoms, as experienced over the last month: vasomotor (items 1–3), psychosocial (items 4–10), physical (items 11–26) and sexual (items 27–29). Items pertaining to a specific symptom are rated as present or not present, and if present, how bothersome on a zero (not bothersome) to six (extremely bothersome) scale. Means are computed for each subscale by dividing the sum of the domain’s items by the number of items within that domain. Nonendorsement of an item is scored a ‘1’ and endorsement a ‘2’, plus the number of the particular rating, so that the possible score on any item ranges from one to eight. The interpretation was done as the higher the mean score, the lower the QOL and vice versa.^9,10

Ethical consideration

Formal permission was obtained from the Institutional Review Committee of College of Medical Sciences-Teaching Hospital (COMSTH-IRC) for ethical consideration (Ref. no. 2020-065). Written permission from the administrative section of the rural municipality of Jhapa was obtained for data collection. Informed consent was obtained from all respondents to ensure their rights. The purpose and objectives of the study were clearly explained to the respondents. The privacy and confidentiality of records were strictly maintained throughout the study.

Statistical analysis

All the collected data were checked, reviewed, coded and organized for their accuracy, completeness and consistency. The data were analysed using Statistical package for Social Science (SPSS) version 16. All collected data were analysed and interpreted in terms of descriptive statistics (frequency, mean, percentage and standard deviation), and inferential statistics (t-test and one-way ANOVA) were used to find out the association between the QOL mean score and the selected sociodemographic variables.

Results

Table 1 depicts the sociodemographic characteristics of the respondents. Most (65.1%) of the respondents were more than 50 years and mean ± SD age of respondents was 53.51 ± 4.42 years. Nearly half (46.5%) were Hindus and majority (81.4%) of them were illiterate. Regarding occupation, most (74.9%) of the respondents were involved in agriculture. Nearly half (57.2%) of the respondents were married. Majority (89.31%) of the respondents had children. The mean number of children was 3.32 ± 1.89. Most (70.7%) of the respondents had low socioeconomic status. Nearly half (49.8%) of the respondents belong to the nuclear families. Most (73.5%) had their menarche before 15 years of age and about two-thirds (63.3%) had their menopause at the age of 45–50 years. The mean age at menopause was 47.18 years. Majority (76.7%) had positive health seeking behaviour.

Table 1.

Sociodemographic characteristics of the respondents (n = 215).

Variables	Frequency	Percentage
Age of the respondents (Mean age: 53.51 ± 4.42)
≤50	75	34.9
≥50	140	65.1
Religion
Hindu	100	46.5
Buddhist	19	8.8
Christian	19	8.8
Muslim	11	5.1
Others	66	30.7
Education
Illiterate	175	81.4
Literate	40	18.6
Occupation
House work	54	25.1
Agriculture	161	74.9
Marital status
Married	123	57.2
Unmarried	25	11.6
Divorced	21	9.8
Widow	46	21.4
Children
Yes (Mean no. of children: 3.32 ± 1.89)	189	87.9
No	26	12.1
Monthly family income
<25,000	152	70.7
>25,000	63	29.3
Family type
Nuclear	107	49.8
Joint	40	18.6
Extended	68	31.6
Age at menarche (Mean age at menarche: 13.91 ± 2.49)
≤15 years	158	73.5
>15 years	57	26.5
Age at menopause (Mean age at menopause: 47.18 ± 6.16)
Early postmenopause (<45 years)	32	14.9
Natural postmenopause (45–50 years)	136	63.3
Late postmenopause (>50 years)	47	21.9
Seeking health service
Yes	165	76.7
No	50	23.3

Table 2 represents the prevalence of menopausal related symptoms of the respondents. On analysis of prevalence of menopausal related symptoms, the most (98.8%) prevalent symptom of menopause was feeling tired from physical domain among all the domains of menopause. Sweating was the most prevalent (58.6%) symptom with mean score ±SD 2.84 ± 1.85 among other symptoms of vasomotor domain. Similarly, poor memory was the most (83.3%) prevalent symptom followed by accomplishing less than she used to (79.5%) with mean ± SD score 3.80 ± 1.69 and 3.12 ± 1.50, respectively, among other symptoms of psychosocial domain. Likewise, feeling tired was the most (98.8%) prevalent symptom followed by decrease in stamina (94%) and decrease in physical strength (91.2%) among other symptoms of physical domain with mean ± SD score of 4.20 ± 1.94, 4.14 ± 1.36 and 3.92 ± 1.29, respectively. Furthermore, avoiding intimacy was the most (54.9%) prevalent symptom among other symptoms of sexual domain with mean ± SD score of 2.92 ± 2.07. The highest mean ± SD scores of MENQOL (2.88 ± 1.61) was seen in physical domain and the least mean ± SD scores of MENQOL (2.45 ± 1.55) was seen in psychosocial domain. The overall MENQOL mean score was found to be 80.06 ± 24.52.

Table 2.

Prevalence of menopausal related symptoms (n = 215).

Menopausal symptoms	Frequency	Percentage	Mean ± S.D
Vasomotor
Hot flushes	110	51.2	2.61 ± 1.89
Night sweats	109	50.7	2.50 ± 1.79
Sweating	126	58.6	2.84 ± 1.85
Psychosocial
Dissatisfaction with my personal life	57	26.5	1.71 ± 1.32
Feeling anxious or nervous	109	50.7	2.34 ± 1.48
Poor memory	179	83.3	3.80 ± 1.69
Accomplishing less than I used to	171	79.5	3.12 ± 1.50
Feeling depressed, down or blue	67	58.8	1.83 ± 1.43
Being impatient with other people	117	54.4	2.55 ± 1.66
Feeling wanting to be alone	62	28.8	1.80 ± 1.45
Physical
Passing gas or gas pains	72	33.5	1.97 ± 1.56
Aching muscle and joints	164	76.3	4.09 ± 2.13
Feeling tired or worn out	178	98.8	4.20 ± 1.94
Difficulty sleeping	106	49.3	2.53 ± 1.88
Aches in back of neck or head	99	46	2.53 ± 1.87
Decrease in physical strength	196	91.2	3.92 ± 1.29
Decrease in stamina	202	94	4.14 ± 1.36
Lack of energy	193	90	3.73 ± 1.36
Dry skin	112	52.1	2.33 ± 1.52
Weight gain	90	41.9	1.87 ± 1.212
Increased facial hair	24	11.2	1.20 ± 0.69
Changes in appearance, texture or tone of my body	165	76.7	2.79 ± 1.31
Feeling bloated	111	51.6	2.39 ± 1.49
Low back pain	176	81.9	4.61 ± 2.21
Frequent urination	82	38.1	2.15 ± 2.29
Involuntary urination when laughing or coughing	87	40.5	1.72 ± 1.77
Sexual
Decrease in my sexual desire	114	53	2.74 ± 1.90
Vaginal dryness	108	50.2	2.53 ± 1.83
Avoiding intimacy	118	54.9	2.92 ± 2.07

Table 3 presents the association of mean score of MENQOL with selected sociodemographic variables. Marital status, no. of children, educational status, occupational status and health seeking behaviour had significant association with the score of MENQOL at p-value 0.05. Based on mean score, unmarried and divorced women had higher scores among those respondents who were married (p = <0.001). Likewise, women with high parity (more than four children) or nullipara had a higher mean score than women with one to four children (p = 0.019), and literate women had a higher score than the illiterate women (p = <0.001). Similarly, women who were house managers had a greater mean score compared to the one who were working (p = <0.001), and the mean score was higher among the one who had health seeking behaviour than the one who did not (p = <0.001). There was no statistical significant difference among other sociodemographic variables.

Table 3.

Association of quality of life of postmenopausal women with selected sociodemographic variables.

Variables	N	Mean±SD	Minimum	Maximum	p Value
Age group
>50	140	80.2 ± 25.5	33	173	0.893
≤ 50	75	79.8 ± 22.8	35	128	0.893
Marital status
Married	123	79.5 ± 24.9	33	156	<0.001
Unmarried	25	88.1 ± 26.9	68	173
Divorced	21	99.8 ± 20.3	73	155
Widow	46	68.2 ± 15.7	45	100
No. of children (parity)
None	23	86.9 ± 16.9	68	126	0.019
1–2	48	73.3 ± 29.1	35	169
3–4	97	78.3 ± 23.5	33	155
>4	47	87.1 ± 22.7	47	173
Educational status
Illiterate	175	76.8 ± 24.1	33	173	<0.001
Literate	40	94.3 ± 21.5	65	169	<0.001
Occupational status
House manager	54	93.6 ± 20.6	47	169	<0.001
Agriculture	161	75.5 ± 24.1	33	173	<0.001
Monthly family income
<25,000	152	78.3 ± 25.6	33	173	0.101
>25,000	63	84.3 ± 21.4	35	169	0.101
Age of menopause
<45 years	32	75.4 ± 15.9	35	113	0.110
45–50 years	136	79.0 ± 25.0	33	155
>50 years	47	86.3 ± 27.2	41	173
Age of menarche
≤ 15	158	78.2 ± 24.7	33	169	0.071
>15	57	85.1 ± 23.5	56	173	0.071
Health seeking behaviour
Yes	165	83.59 ± 24.26	44	173	<0.001
No	50	68.40 ± 21.81	33	108	<0.001

Discussion

The overall MENQOL mean total score among the respondents was 80.06 (±24.52) in this study which is lower to the finding of the study conducted in Kochi, 112.47 (±28.80) and Sikkim, 136 (±28.78).¹¹ Higher scores indicate the severity of the symptoms.

Though a review of global studies put the age-range of menopause onset at 42–51 years with a mean average of 46.7 years, age at menopause and symptoms varies among populations and societies. Studies indicate that women living in developing countries experience natural menopause several years earlier than those in developed countries. The average age of menopause for women from industrialized countries ranges between 50 and 52 years.^12–14 In the present study, the mean age of menopause was found as 47.18 (±6.16) years which is comparable to the findings of earlier studies conducted in India, Pakistan and Nepal that show a range between 46 and 49 years.^12,15,16 This finding corresponds to the finding for the age range of developing countries.

Menopausal symptoms have negative impact on QOL among women. Epidemiological studies reported higher prevalence (40%–60%) of physical, psychological, vasomotor and sexual disorders among menopausal women and a positive linear relationship between menopausal changes and QOL.¹⁷ Physical domain was the most affected domain of MENQOL in this study which is consistent with the result of the studies conducted in Pakistan and India^12,17 but opposed by the finding of a study conducted in Kapilvastu, Nepal, where the most common problems experienced by menopausal women were among the sexual domain.¹⁸ The least affected domain in this study was psychosocial domain which is different to the finding of the study conducted in Egypt where least mean score was seen in physical domain whereas higher mean score in the sexual domain.²

Feeling of tiredness and worn out was the most prevalent symptom followed by decrease in stamina and decrease in physical strength. The finding is comparable to the findings of a study conducted in Kaski district of Nepal.¹⁶ In contrast to the finding, Sagdeo and Arora in a comparative study in rural and urban women showed the most common problem as joint and muscular symptoms followed by hot flushes and night sweats.¹⁹ In another study conducted by Karmakar N et al., the most prevalent symptoms reported were feeling of anxiety and nervousness, feeling tired and decrease in stamina.¹⁵ In addition in the study conducted in Nepal among 2000 women, it was found that sweating, hot flushes, joint/muscle pain were the most common menopausal symptoms known by the women.²⁰ The least experienced symptom was increase in facial hair which is in contrast to the finding of a study conducted in rural Puducherry where sexual desire was the least prevalent symptom.²¹

The most prevalent symptoms reported in vasomotor domain were sweating, followed by hot flushes and night sweats in this study. Similar to the finding, a study conducted in rural Puducherry had sweating as the most frequent occurring symptom.²¹ The findings are opposed to the study conducted by Paudel et al. where hot flushes was the most frequently reported symptom.²² The prevalence of menopausal symptoms may show differences due to the geographical variation.

Poor memory was the most prevalent symptom in psychosocial domain which was similar to the findings of other two studies.^2,21 Followed by poor memory, our study revealed the frequent occurring symptoms like accomplishing less than they used to do, feeling depressed down or blue and being impatient with others.

Feeling tired or worn out, decrease in stamina, decrease in physical strength and lack of energy were the most frequent symptoms in physical domain. Nevertheless, joint pain was the most experienced symptom among the postmenopausal women in other studies.²¹

Avoiding intimacy was the most (54.9%) prevalent symptom among other symptoms of sexual domain followed by decrease in sexual desire and vaginal dryness. In contrast to the findings, study conducted in Nepal and India showed vaginal dryness as the major prevailed symptom.^23,24

Previous studies that evaluated the relationship of QOL of menopausal women and sociodemographic variables reported that marital status, parity, educational level, occupational status and health seeking behaviour were related to QOL; the results were confirmed in this study also.^25,26

Women who were married had better QOL than those of the unmarried and divorced ones. This result is in contrary to the finding of a study conducted by Ray and Dasgupta where low QOL was associated with the deterioration of the relationship with husband after menopause.²⁷

The present study found statistically significant difference in parity in relation to the MENQOL score revealing that either nullipara or grandmultipara had lower QOL. The findings are in agreement with the study report of Sri Lanka. The study further added that more children in the family would add more worries and responsibilities resulting in poor QOL.²⁸ Similarly, the worries of not having anyone also puts them at risk of developing poor QOL.

Previous studies that evaluated the association between education and QOL reported that higher the education level, higher is their QOL. Educated people usually tend to have improved health related QOL because of knowledge regarding healthy behaviour practices, application of preventive approaches and positive life style. However, in this study, being literate was found to have higher MENQOL scores in comparison to the illiterates. It was well supported by the finding of two other studies.^1,27 It may be because educated ones could easily identify the problems and the illiterate were confused with the presentation of the symptoms. In general, literacy is more connected to being aware about our health condition and here being literate might have led the women to report the symptoms easily.

Being employed had a significant effect on MENQOL scores. Similar to the finding of our study, the studies conducted by Kalarhoudi et al and Ganapathy et al had higher MENQOL scores.^17,29 However, in contrast to the finding, Kaulagekar reported the prevalence of menopausal symptoms as comparatively minimal in homemakers when compared to the employed women (76% vs 85%).³⁰

The majority (76.7%) in our study had positive health seeking behaviour which is similar to the study carried out in Nepal as well as in Nigeria.^22,31 But the study conducted in Pune had only less than half percentage of the respondents seeking health services for any treatment.³⁰ However, the MENQOL score was higher among the women who were having positive health seeking behaviour. This may be because they are seeking the health services after they have been experiencing a lot of menopausal symptoms for its management.

Conclusion

Menopause is a transitional period, and it certainly demands a lot of physical and mental changes. Menopause involves all symptoms related to vasomotor, psychosocial, physical and sexual issues. The most common menopausal symptoms reported in this study were from the physical domain: feeling of tiredness, decrease in stamina and decrease in physical strength. Marital status, educational status, parity and occupational status were significantly associated with QOL scores.

Menopausal symptoms should be assessed to identify the problems and solve them. Hence the main focus lies on increasing the awareness regarding menopausal symptoms so that the women can identify it and do seek proper medical and health care services. The awareness programme can be imparted by the health care professionals from the primary level both at individual and community basis.

Limitation of the study

This study was conducted in one rural municipality located in Eastern Nepal, and the findings of the study may not be generalizable for urban communities (with different customs, cultures and lifestyles).

Implication of the study

The study has implications for research, practice and education. Health care providers at the primary level can play a vital role in providing awareness regarding menopausal symptoms and the simple management methods such as lifestyle modification, changes in dietary habits, yoga, meditation, etc. Proper health assessment can be performed by the professionals to determine early the necessity of any treatment.

Recommendation

Comparative studies on QOL of postmenopausal women between rural and urban areas can be done in larger population to generalize the findings. Further studies on the impact of educational interventions, yoga, meditation and lifestyle modification are necessary to better the QOL of postmenopausal women.

Footnotes

Acknowledgements

The research team would like to thank all the participants of the study for providing their valuable time and information.

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Pratima Thapa

References

Charandabi

Rezaei

Hakimi

, et al. Quality of life of postmenopausal women and their spouses: a community-based study. Iran Red Crescent Med J 2015; 17: e21599.

WHO EMRO. Quality of life among postmenopausal women in rural Minia, Egypt. East Mediterr Health J 2017; 23: 527–533, http://www.emro.who.int/emhj-volume-23-2017/volume-23-issue-8/quality-of-life-among-postmenopausal-women-in-rural-minia-egypt.html

Paulose

Kamath

Quality of life of postmenopausal women in urban and rural communities. J Menopausal Med 2018; 24: 87–91.

Avis

Assmann

Kravitz

, et al. Quality of life in diverse groups of midlife women: assessing the influence of menopause, health status and psychosocial and demographic factors. Qual Life Res 2004; 13(5): 933–946.

Ham

OK.

Predictors of health-related quality of life among low-income midlife women. West J Nurs Res 2011; 33: 63–78.

Col

Haskins

Ewan-Whyte

CJ.

Measuring the impact of menopausal symptoms on quality of life: methodological considerations. Menopause 2009; 16: 843–845.

Mohamed

Lamadah

Zamil

Quality of life among menopausal women. Int J Reprod Contraception Obstet Gynecol 2014; 3: 552–561.

MGH Center for Women’s Mental Health. The effects of yoga and exercise on menopausal quality of life, https://womensmentalhealth.org/posts/yoga-exercise-menopausal/ (accessed 03 September 2020).

Lewis

Hilditch

Wong

CJ.

Further psychometric property development of the Menopause-Specific Quality of Life questionnaire and development of a modified version, MENQOL-Intervention questionnaire. Maturitas 2005; 50: 209–221.

10.

Hilditch

Lewis

Peter

, et al. A menopause-specific quality of life questionnaire: development and psychometric properties. Maturitas 1996; 24: 161–175.

11.

Senthilvel

Vasudevan

Anju

, et al. Assessment of symptoms and quality of life among postmenopausal women in a tertiary care hospital in Kochi, South India: a hospital-based descriptive study. J Midlife Health 2018; 9: 185.

12.

Nisar

Sohoo

Sikandar

Age and symptoms at natural menopause: a cross-sectional survey of rural women in Sindh Pakistan.

J Ayub Med Coll Abbottabad 2012; 24: 90–94.

13.

Gold

EB.

The timing of the age at which natural menopause occurs. Obstet Gynecol Clin North Am 2011; 38: 425–440.

14.

Hinchliff

Menopause. In: Encyclopedia of Gerontology and Population Aging. Cham: Springer International Publishing, 2019: 1–5.

15.

Karmakar

Majumdar

Dasgupta

, et al. Quality of life among menopausal women: a community-based study in a rural area of West Bengal. J Midlife Health 2017; 8: 21–27.

16.

Koirala

Thapa

Shrestha

Quality of life of postmenopausal women of Kaski district. Nepal J Obstet Gynaecol 2020; 15(1): 43–49.

17.

Ganapathy

Al Furaikh

Health-related quality of life among menopausal women. Arch Med Health Sci 2018; 6: 16–23.

18.

Ghimire N, Dhakal P, Norrish Det al. Menopausal health status of women of Kapilvastu district of Nepal. J Nepal Health Res Counc 2015; 13: 182–187.

19.

Sagdeo

Arora

Menopausal symptoms: A comparative study in rural and urban women. JK Science 2011; 13: 23–26.

20.

Rajbhandari

Subedi

Dangal

, et al. Menopausal health status of Nepalese women. J Nepal Med Assoc 2017; 56: 107–111.

21.

Surendar

Durgapriya

Arthi

, et al. Quality of life among post-menopausal women in rural Puducherry. Public Health Rev 2019; 6: 112–118.

22.

Paudel

Bhattrai

Adhikari

, et al. Gynaecological and other health problems of postmenopausal women and their health seeking behaviour in rural Terai, Nepal. Health Renaiss 2015; 12: 87–91.

23.

Prajapati

Shrestha

Sanjel

Quality of life of menopausal women in Majhifeda VDC, Kavrepalanchok, Nepal. Kathmandu Univ Med J 2018; 16: 311–316.

24.

Devi

Quality of life of post-menopausal women residing in rural and urban areas of Sikkim, India. Int J Reprod Contracept Obs Gynecol 2018; 7: 5125–5133.

25.

Shobeiri

Jenabi

Hazavehei

SMM

, et al. Quality of life in postmenopausal women in Iran: a population-based study. J Menopausal Med 2016; 22: 31.

26.

Ehsanpour

Eivazi

, et al. Quality of life after the menopause and its relation with marital status. Iran J Nurs Midwifery Res 2008; 12.

27.

Ray

Dasgupta

An assessment of QOL and its determining factors of post menopausal women in a rural area of West Bengal, India: a multivariate analysis. Int J Med Public Health 2012; 2: 12–19.

28.

Rathnayake

Lenora

Alwis

, et al. Prevalence and severity of menopausal symptoms and the quality of life in middle-aged women: a study from Sri Lanka. Nurs Res Pract 2019; 2019: 1–9.

29.

Abedzadeh Kalarhoudi

Taebi

Sadat

, et al. Assessment of quality of life in menopausal periods: a population study in Kashan, Iran. Iran Red Crescent Med J 2011; 13: 811–817.

30.

Kaulagekar

Age of menopause and menopausal symptoms among urban women in Pune,

Maharashtra. J Obstet Gynecol India 2011; 61: 323–326.

31.

Dienye

Judah

Ndukwu

Frequency of symptoms and health seeking behaviours of menopausal women in an out-patient clinic in Port Harcourt,

Nigeria. Glob J Health Sci 2013; 5: 39–47.