Introduction

Menopause is defined as generally cessation of periods for 12 months or a period equivalent to three previous cycles or as time of cessation of ovarian function resulting in permanent amenorrhoea₁. Menopause is said to be a universal reproductive phenomenon, which can be perceived as unpleasant. This period is generally associated with unavoidable manifestation of aging process in women₂.

Currently men and women in India in the 60 plus age group number 60 million i.e. about 6% of the population. Projection for the year 2025 shows that aging population would increase to about 12% of the total and roughly half of this population will be women in the elderly age group₃.

According to IMS (Indian menopause society) research there are about 65 million Indian women over the age of 45. Average age of menopause in around 48 yrs but it strikes Indian women as young as 30-35 years. So menopausal health demands even higher priority in Indian scenario₄.

. In present era with increased life expectancy, women are likely to face long periods of menopause accounting to approximately a third of her life. Menopause is accompanied by biological and psychological changes that affect a women's health and sense of well being. Menopause may be smooth experience for some women with only symptom of cessation of menstrual flow while others face one or more of post menopausal symptoms. But there is lack of awareness of its cause, effect and management pertaining to it. A wide gap in the knowledge has been documented in the women from developed and developing countries. And this gap is even wider in women from slums and urban area in developing countries₅.

Another significant phenomenon in this age group is the post menopausal bleeding(PMB) which is likely to be misinterpreted to be a normal phenomenon. But this can spell disaster as it may be the warning signal for cancer cervix. This demands raising awareness about the gynaecological examination along with pap smear₁.

Many studies have been conducted related to various aspects of menopause. But majority are confined to the awareness pertaining to menopause and related aspects. A dearth of data is there related to the post menopausal bleeding . In our study an effort has been made to compare the knowledge and prevalent symptoms related to menopause along with post menopausal bleeding among residents of slums and urban area.

Methodology

The community based, cross-sectional study was conducted in the field practice area of Urban Health Training Centre of Department of Community Medicine, Govt. Medical College and Hospital, Chandigarh, and the adjoining largest slum. The study was carried out between Jan 2007 – May 2007.

The study population comprised of women above 40 years and resident of the study area. Systematic random sampling was used. Every 5^th house was visited in both urban and slum area for data collection. The study was done by interview technique using pre-tested and pre-designed questionnaire by the team of trained social workers, interns and medical officers.

Women who fulfilled the inclusion criteria were interviewed after taking the consent and explaining them the purpose of study. Detailed information was collected from those who had attained menopause. A total of 602 women were contacted. Out of that 74 did not give the consent owing to shortage of time (31) and some (43) being not interested. Hence, 528 women were interviewed, out of which 302 were from urban area and 226 were resident of slum.

Socio-demographic information was collected along with awareness about menopause. Data was also gathered regarding prevalence of menopausal symptoms and treatment they resorted too. Study subjects who had postmenopausal bleeding were referred to gynaecology and obstetric department of Govt. Medical College and Hospital, Chandigarh for through examination and further management. Locked houses or the women who did not give consent for the interview were not included in the study. The data was collected, compiled and analyzed using epi-info and SPSS version 12..

Results

Out of total 528 women interviewed, 302 (56.1) were residing in urban area and rest were the residents of slums. The mean age of urban women who were interviewed was 48.4 yrs as compared to 46.2 yrs of slums. Mean parity in slums was 4 which was higher than that of urban area, 2.5. Out of 302 females from urban area, 78.8% had attained menopause while 60.2% of the 226 study subjects taken from slums have attained same.

Most of the females from urban area were educated at least up to middle where as in slums almost half of the females were illiterate. 70% women who were interviewed were housewives followed by 14.9% who were doing some job. Majority (89%) of the study subjects was married and 9.1% were widows.

Majority (70.3%) of urban residents have heard about menopause as compared to 30.9% in slums but out of them only 8.5% had the correct knowledge about menopause. 65.6% of urban females compared to 21.2% of slum females think that menopause in harmful. Urinary (12.1%) problems followed by weak bones (9.5%) were the most common harmful effects narrated by study subjects. Besides that weight gain (8.7%), BP changes (8.1%) and disturbed sleep were other common problems narrated.

Out of 71.4% of the total females who have attained menopause at the time of study, 42.7% had vaginal irritation / discharge. 41.1% of urban females complained of joint pains and swelling while weakness (48.5%) was the commonest menopausal symptom felt by the slum females. 33.2% of urban and 16.9% of slum females narrated loss of sex drive.

Less than half of females (38. %7) ever took treatment for menopausal symptoms. 61.2% of urban and 70% of slum females took calcium to treat menopausal syndrome. Soya products were taken by only 10.3% of the total while hormonal pills were consumed by 21.9% of the females. Majority o f females who took treatment for the menopausal symptoms 88.4% took it without doctors advise.

29(7.7%) females complained of PMB out of which 13(44.8%) had PMB after intercourse. PAP smear was done only in 8 (27.6%) patients out of which 7 (38.9%) were from urban area. 50% of females who had undergone PAP smear were prompted by doctors.

Out of total menopausal women 171(70.9%) of urban females and 41(30.9%) of slums thought PMB was dangerous. 45.1% were aware of PAP smear out of which majority were the residents of urban area. Right age of PAP smear was narrated by 7(1.9%) females only, out of which all were urban residents. No female from slum could tell the right age for PAP smear.

Only 2(28.6) women got their pap smear done after being suggested by doctor and they were from urban area only.

Figure 1

Table 1: demographic profile of respondents

Figure 2

Table 2: awareness of menopause and related problems

Figure 3

Table 3: treatment profile of women for menopausal syndrome

Figure 4

Table4 : Awareness Of The Significance And Prevalence Of Post Menopausal Bleeding In Females

Discussion

In India, there is no current health programme that caters the specific reproductive health needs of aging women. Moreover, recently launched RCH II (reproductive and child health) and NRHM(national rural health mission) programmes, that are means to comprehensively cover health aspects of women and children, only addresses women in the reproductive age group, ignoring those who have passed the reproductive stage.

In our study it was elicited that there was lack of awareness about menopause and related problems especially to post menopausal bleeding. The range of menopausal age seen in Indian women varies from 40.3-44.8yrs₆ and in developed countries range is from 48-51yrs₇. Mean menopausal age in urban women was found to be 45.3yrs as compared to that residing in slum, 43.8yrs. The results corroborated to the findings of another study done in rural population of Chandigarh₈, 44.1yrs. Another study in African women₂ showed the mean menopausal age to be 49.5yrs.

Diversity in attainment of menopause may be due to regional, community and either variations. Genetic, environmental and nutritional factors also play role₉. Around 70% women in urban area and 30% in slum had heard of menopause but the correct knowledge (amenorrhoea for 12m) was known to only 1/10^th of women in urban area and 1% women in slums. Mashiloane₂ too found the awareness to be around 80% in African women.

More than half of urban respondents considered menopause to be harmful because of physical and psychological impact on health. Whereas it was welcomed by majority (44.2%) of slum respondents because of getting freedom from monthly bleeding. Kaur₁₀ too found that 94% of rural women happily accepted menopause.

Majority of the population of the urban of the field practice area comprises of geriatric age group that's the reason that majority of women (80%) who were contacted had attained menopause. The study reveals varying nature of menopausal symptoms. The most common being vaginal irritation / discharge in urban subjects as compared to generalised malaise in slum subjects. The findings were similar to that of Sharma₁₁ and Damodaran₅, who also found the generalised malaise and vaginal irritation to be commonest symptom in contrary to Kaur₁₀ and Singh₈ who found diminished vision to be a common symptom. Other studies₁₂, ₆ found loss of interest and joint pains in majority of females. Other common symptoms were irritable behaviour and loss of sexual drive, which were also evident in other studies₉. Lot of research₁₃,₁₄ done in developed countries too that showed mood swings, vaginal irritation, weight gain and fatigue to be predominant symptoms.

At one level, there is low awareness on post menopausal syndrome and at the other women rush into all available modes of treatment. Majority of women were not aware of therapy of menopause and fewer had heard of hormonal therapy Results were similar to that of Singh₈, Kaur₁₀ and Mashiloane₂. But around 40% of respondents had resorted to same form of treatment like intake of calcium supplement, soya products. These respondents consisted of that section of study population who were regular visitor of our training center and were made aware of menopausal symptoms and were given symptomatic treatment.

Another interesting finding of the study was the inclination of women towards alternate medicine (homeopathic) along with yoga and meditation. Mallik₁₅ has also reiterated in his study that today modern medicine may be sending conflicting signals in hormone therapy but complementary medicines have a well articulated approach to the management of menopause₁₆.

Postmenopausal bleeding represents one of the common reasons to suspect an underlying cancer. Around 30-50% of the patients with these symptoms suffer of cancer of reproductive treat₁₇

Less than 1/10^th of women had PMB and of these less than half had it after sexual intercourse. The women with PMB were made aware of the various causes of it and were suggested for pap smear examination. But it was found that only one third of women got their pap smear done. This depicts that even though making them aware about the significance of PMB, women were not sensitized. This shows the gravity of situation and needs more emphasis on imparting the knowledge in the masses because it is evident from many studies that pap smear, a cost effective approach for cancer screening has decreased the incidence to a great extent in developing countries.

Conclusion

Our study highlights that there is lack of awareness regarding menopause and related aspects especially PMB in both urban and slum population. Results show that there is a need to educate women regarding an early identification of common menopausal symptoms as well for the various causes and significance of PMB. Moreover efforts have also to be done by higher authorities for redressal of grievances of this segment of women by initiating various strategies and programmes.