Study of epidemiological features of health problems in perimenopausal and postmenopausal women in an urban community

Introduction: Menopause is said to be universal reproductive phenomenon. Menopause although not a disease is associated with annoying physiological changes and varied symptoms such as hot fl ushes, night sweats, urinary and genital changes, dyspareunia, insomnia and many psychological dysfunctions such as anxiety, depression, lack of concentration and decreased self-esteem. Every woman’s experience of the menopause is unique; she may experience all of the symptoms or none of them. Some fi nd the transition barely noticeable while others fi nd it life altering. Materials and Methods: A cross-sectional study was conducted among peri and postmenopausal women aged 40-60 years residing at Government colony, Bandra, Mumbai, Maharashtra for a period of 1-year. A predesigned and pretested questionnaire was used for collecting data. A booklet on “care during menopause” was used for giving health education. Results: In this study, mean age at natural menopause was 45.32 years (standard deviation ±2.79). Our study participants reported mostly muscular and joint pain (44.86%), urological symptoms (23.43%), vasomotor symptoms (21.14%), vulvovaginal symptoms (19.43%), psychological symptoms (15.14%), weight gain (14.86%), psychosexual symptoms (11.43%) and hirsutism (1.43%). Conclusions: There is a necessity of a multidisciplinary approach to the problems of menopause with more stress on promotive and preventive interventions. There should be provision of relevant health services, health education and promotional activities to cope up with the health needs of women in their postmenopausal years.


INTRODUCTION
Menopause is said to be universal reproductive phenomenon. All the women who live beyond the age of 45-50 Years, experience a period of transition from reproductive to the nonreproductive stage of life. [1] Natural menopause is recognized after 12 consecutive months of amenorrhea for which there is no obvious pathological or physiological cause. [2] The word climacteric is used to refer to a wide variety of physiological changes occurring in the years immediately surrounding the menopause. [3] The years prior to menopause that encompass the change from normal ovulatory cycles to cessation of menses is known as perimenopausal transition [4] and the term postmenopause is defi ned as dating from fi nal menstrual period regardless of whether the menopause was induced or spontaneous. [5] hot fl ushes, night sweats, urinary and genital changes, dyspareunia, insomnia and many psychological dysfunctions such as anxiety, depression, lack of concentration and decreased self-esteem. Thus, it affects the quality of life by being major cause of morbidity and acts as a risk factor for early mortality from subsequent chronic diseases like ischemic heart disease, osteoporosis.

Objectives
1. To identify sociodemographic factors associated with perimenopausal and postmenopausal women. 2. To study menopause associated health problems in them. 3. To impart health education to improve overall health status of perimenopausal and postmenopausal women. Of these 415 women, 8 refused to participate in the study and 7 had undergone hysterectomy, they were excluded. Hence, total sample size for the study was 400. A structured questionnaire was prepared. First part of the questionnaire included sociodemographic data such as age, religion, education, occupation, marital status, income etc. and the second part included questions related to symptomatology of menopause and detail general and systemic examination. Psychological symptoms were assessed using hamilton depression rating (HAM-D) scale. [11] A pilot study was conducted to assess feasibility of the study tools (interviews and questionnaire), to estimate the required time for fi lling the questionnaire and for data collection and to evaluate questionnaire's reliability, for which 50 women from total sample were selected randomly. The sample taken for pilot study was excluded from total sample for fi nal study. Hence, fi nal sample size for the study was 350. The proposal was approved by Institutional Ethical committee. Informed consent of all eligible participants was taken for participation in the study and prior to the interview. After fi lling the proforma, health education was given to each women for which a booklet on "care during menopause" was used. This booklet contains all the basic information regarding menopause, its symptomatology, home remedies, diet and exercises during menopause etc. Assigned women were then asked to come for clinical examination at UHC Bandra on appointed Saturday. Examination included detail general examination and systemic examination and relevant investigations.

Data analysis
Pearson's Chi-square test is applied to test the association of categorized independent and dependent variables. If expected number in the cell was below 5 in a table, Fischer's Exact Test (Exact two-sided) was used. P <0.05 is considered as statistically signifi cant. Means and standard deviations (SD) were calculated. Stata SE 10.1, (StataCorp LP, Texas, USA) was used to analyze data.

DISCUSSION
In this study, mean age at natural menopause is 45.32 years (SD ± 2.79). In a study, conducted by Shah et al. among the women in Mumbai, the mean age at menopause was 44.7 years. [12] In a study, conducted by Kapur et al. among women in the Haridwar district of Uttarakhand, a state located in northern India, mean age at menopause was 46.82 years. [13] In another study, conducted by Sharma et al. [14] among urban women in Jammu, the mean age at menopause was 47.35 years. Mean age at menopause in Indian women is less in comparison to women from developed countries. It varies from country to country even in the same country in a different region. These diversities may be because of regional, community and ethnic variations. Genetic and environmental and nutritional factors may also play a role.
No signifi cant association was found between age at menopause and religion, education, employment status, marital status, SES, age at menarche, parity. Our fi ndings are consistent with Kriplani and Banerjee, [15] Pedro et al. [16] and Blumel et al. [17] who found no association between the various sociodemographic, cultural and reproductive factors and age at onset of menopause.
Although hot fl ashes are the most common symptom reported by many other Indian as well as studies in western countries, our study subjects reported mostly muscle and joint pain (44.86%), urological symptoms (23.43%), vasomotor symptoms (21.14%), vulvovaginal symptoms (19.43%), psychological symptoms (15.14%), weight gain (14.86%), psychosexual symptoms (11.43%) and hirsutism (1.43%). Prevalence of vasomotor symptoms (hot fl ashes and night sweats) is much lower than that of the western countries. Hot climate of our country may mask the similar symptoms associated with climacteric.
Next in the frequency was a urinary complaints (23.43%), including increase frequency of micturition, stress incontinence, urge incontinence. All urinary symptoms were common in the age group of 50-54 years. Vulvovaginal symptoms (19.43%) followed urological symptoms. Of this Vaginal dryness was present in 25%, Leucorrhoea was present in 61.76% and vaginal irritation was present in (13.24%) and psychosexual symptoms including loss of libido and dyspareunia was present in 13.70%. In a study, conducted by Jahanfar et al. [18] among Malaysian women, 42.8% of menopausal women reported vaginal dryness including sensation of dryness or burning in the vagina, diffi culty in the sexual intercourse, but only 21.4% reported sexual problems inclusive of change in sexual desire, in sexual activity and satisfaction, this seems to be best explained by the physical changes associated with reduced estrogen levels in menopause.
Psychological symptoms were present in 15.14% women, out of which, irritability constituted (30.19%), insomnia (26.42%), anxiety (15.09%), lack of concentration (15.09%). Psychological symptoms were more in postmenopausal women (12.57%) as compared with perimenopausal women (5.45%). Statistically, also it was found to be signifi cant. Those women who were having psychological symptoms were assessed for depression using HAM-D scale, [11] depression was present 13.21%, it was more common in perimenopausal women (22.22%) as compared to postmenopausal women (11.36%), but statistically it was not found to be signifi cant. About 14.86% women in our study had a history of weight gain. perimenopausal women (25.45%) gained more weight than postmenopausal women (5.41%).
In a study, conducted by Von Mühlen et al. [19] on menopausal women, 45% of women had propensity to gain weight.
Main strengths of our study are this is community-based study, which has helped to make aware the women about menopausal symptoms and we also tried to give health education through a booklet care during menopause, which is of prime importance and also distributed the copies of same to every participant. The study also had some limitations. The assessment methods were quite subjective. As menopause is a retrospective event, recall bias may occur. Due to time constraint follow-up of the participants could not be done.

CONCLUSION
Commonest symptom in our study was muscle and joint pain followed by urological complaints, vasomotor symptoms, vulvovaginal symptoms, psychological symptoms, weight gain, psychosexual symptoms and hirsutism. Menopausal symptoms are either ignored or not spoken of. It is suggested that establishment of menopausal clinic within the current primary health care system can centralize attention to menopausal women and their needs. There is a necessity of a multidisciplinary approach to the problems of menopause with more stress on promotive and preventive interventions. National health authorities should examine the implications of the projected rapid growth in the number of postmenopausal women between 1990 and 2030. They should anticipate the provision of relevant health services, health education and promotional activities to cope up with the health needs of women in their postmenopausal years.