Introduction

Although menopause is a phenomenon that affects women of all races and social strata¹, the appreciation of its medical importance varies widely amongst different societies^{2, 3, 4}. In the developed countries of Europe and North America, the adverse impacts of menopausal symptoms on the quality of life of the affected women have been widely acknowledged for decades now^5,6,7,8. Consequently, appropriate remedies have been developed to treat them. These include hormonal and non-hormonal therapies^9,10,11,12. Hormone replacement therapy (HRT) is especially effective for the treatment of severe vasomotor and oestrogen-deficient mucosal symptoms as well as in slowing down the rate of bone demineralization^4,7,8. The preliminary results of the Women’s Health Initiative study (WHI) raised some issues about the safety profile of HRT, especially its associations with breast cancer and cardiovascular diseases¹³. Emerging evidences tend to support short-term use of HRT for severe menopausal symptoms and its avoidance for long-term prophylaxis¹⁴. HRT has, therefore, remained the mainstay of the treatment of severe menopausal symptoms¹⁵.

Until recently, researches on menopause had received little attention in the developing countries, including Nigeria. It has recently been reported that Nigerian women experience most of the common menopausal symptoms^16,17. Although some socio-cultural factors have been reported to enable some Nigerian women with mild and moderate menopausal symptoms to cope without medical treatment, other women are also known to present with severe symptoms that require effective medical treatment¹⁶. Unfortunately, treatment of severe menopausal symptoms in most Nigerian hospitals often consists of ‘psychotherapy’, analgesia and anxiolytics and rarely includes the use of HRT¹⁸. From their study in a rural community in Nigeria, Agwu and colleagues¹⁷ reported that menopausal women who received treatment for their menopausal symptoms from the hospitals considered such treatments ineffective. They suggested that the ineffective hospital-based treatment of menopausal symptoms might be one of the reasons why many Nigerian women believe that menopausal symptoms are not amenable to orthodox medical treatment. In Enugu Nigeria, women rarely present to the Gynaecologist with menopausal symptoms despite the reported high prevalence of such symptoms amongst menopausal women in the city¹⁶. It is not known whether this is because the women are able to cope without treatment or because they seek treatment of their symptoms from other sources. The study objectives were to determine the proportion of menopausal women who seek treatment for menopausal symptoms and their sources of treatment.

Materials and Method

The data for this study was collected as part of a comprehensive study on menopause among the Igbo women in Enugu, part of which has been previously reported¹⁶. The study was a cross-sectional survey of post-menopausal women. Menopausal women seen by the author at the University of Nigeria Teaching Hospital and the Annunciation Specialist Hospital (a faith-based organization hospital) both in Enugu over a two-year period were the subjects of this study. Enugu, the capital of Enugu State of Nigeria and the former capital of Eastern Region of Nigeria, is inhabited predominantly by people of the Igbo ethnic group¹⁹. Menopausal women aged 40 years and above, of Igbo origin and without history of previous oophorectomy, qualified for inclusion in the study. Patients who were not of Igbo ethnic origin and those who declined consent were excluded along with those who did not meet the inclusion criteria. A pilot to field-test the questionnaire used for this study had revealed that menopausal symptoms such as “hot flush”, “irritability” and “depression” do not have one-word local equivalents but are usually described with phrases. A focus group discussion was organized with menopausal women members of a church in Enugu to identify the common descriptive phrases for menopausal symptoms. For the study proper, the identified descriptive phrases for each menopausal symptom were listed against it as a checklist thus (the local descriptive phrases are written in bold italics below and closed in parenthesis):

Body/joint pain (Ahu mgbu, okpukpu mgbu, mgbu na njikwo okpukpu)

Hot flushes (ikpo oku n’ime ahu nke oke osisoo n’esochi, inwu oku n’ime ohu)

Urinary symptoms (nsogbu n’inyu mmamiri, inyu mmamiri ugboru ugboru, mmamiri iwa madu owuwa)

Easy fatigability (ike ogugu n’atufughi oge, ike ogugu na nwa mgbe oge)

Irritability (mgbakasi ahu)

Night sweat (oke osisoo nke n’agba n’ime abani)

Dryness during sexual intercourse (ahu nwanyi ikpo nku n’oge mmeko nwoke na nwanyi, ahu nwanyi ifu ufu n’oge mmeko nwoke na nwanyi)

Insomnia (ura igba-oso na abani, ura ekweghi arahu)

Crawling sensation (ihe igaghari n’ahu)

Depression (ike uwa igu madu, uto ndu ila, ururu ikpuchi ndu)

Following consent for participation, consecutive eligible respondents were interviewed with the aid of the pre-tested, researcher-administered, semi-structured questionnaires which contained questions on their socio-demographic data, age at menopause, menopausal symptoms experienced, treatment ever received for the menopausal symptoms, sources of the treatments and awareness of HRT. Data collation and analysis were done using SPSS version 15. Descriptive and correlation statistics were done. Level of statistical significance was at P≤0.05, 90% confidence interval. The research ethics committee of the University of Nigeria Teaching Hospital Enugu approved the study.

Results

A total of 209 respondents were recruited for the study. Their mean age at menopause was 48.24 (range: 40-57 years). The age at menopause did not influence the type of symptoms and the severity of symptoms (p>0.05). The prevalence of the menopausal symptoms is shown in table 1. Every respondent had one or more menopausal symptoms. Body pains and joint pains, hot flushes and urinary symptoms were the commoner symptoms reported. Eighteen (8.6%) women described their symptoms as severe, 35(16.8) described theirs as moderate while the remaining156 (74.6%) described their symptoms as mild. Having joint and body pains as well as hot flushes were significantly associated with describing symptoms as severe (p=0.03 and p=0.01 respectively). Body pains and hot flushes were more common among women who had been post-menopausal for less than 5 years than in those who had been post-menopausal for 5 years or more (p<0.05 for both symptoms). Only 2 (0.96%) of the women were aware of HRT and none of them had ever received HRT. One hundred and seventy-six respondents (84.2% of respondents) had ever received some form of treatment for the menopausal symptoms while 33 (15.8%) had not. Each of those who had ever received treatment for menopausal symptoms had received treatment from at least two sources. Their sources of treatment for menopausal symptoms are shown in table 2. They include herbal medicine practitioners 156 (74.6%), patent medicine dealers and medicine vendors 125 (59.8%), “men of God” (priests, pastors and prayer houses) 89 (42.6%), and health care facilities (hospitals and health centres) 39 (18.7%).

Figure 1

Table 1: Symptoms of menopause amongst the Nigerian Igbo women (N=209)

Figure 2

Table 2: Sources of treatment for menopausal symptoms among Nigerian Igbo women.

Discussions

The age of menopause recorded in this study is within the 51±3 ^{years documented for Britain8 and similar to the international mean menopausal age [1]. Except for fracture and memory loss, most known menopausal symptoms6,20,21 were prevalent amongst the study population. Moreover, the respondents were aware that these symptoms were related to their menopausal status and they have local names and phrases for most of the symptoms. The low prevalence of memory loss and fracture may represent the true prevalence of these conditions in the studied population. However, they might have resulted from the study design which recruited the respondents from gynaecology clinics. In the environment of the study, women with fractures are more likely to be found in the homes of traditional bone-setters or orthopaedic hospitals than in the gynaecology clinics. Similar probabilities apply to those with memory loss who would more likely be found in the ‘prayer houses’ and psychiatric hospitals than at gynaecology clinics. An appropriately designed community-based study would be required to determine the true prevalence of menopause-induced fracture and memory loss in this environment.}

The two women who were aware of HRT learnt about it when they visited the United Kingdom. The low awareness of HRT in this environment may reflect its low awareness amongst health workers. Most people in the public get information about medical interventions or treatment modalities from healthcare providers. A recent study by the author revealed that most Nigerian Gynaecologists do not prescribe HRT for menopausal symptoms¹⁸. Increased awareness of HRT among healthcare providers and its increased prescription by health workers would result to increased awareness among the lay public.

The study revealed that most of the women with menopausal symptoms had received some form of treatment for the symptoms. They preferred the herbal medicine practitioners, unprofessional drug sellers (patent medicine stores and medicine vendors) and the “men of God” (priests, pastors and prayer houses) much more than the orthodox healthcare providers in hospitals and health centres (doctors and nurses). In this environment, hospital consultation is usually the last resort when other sources of treatment have failed. The herbal medicine practitioners live in the same communities as the women, provide cheap services and often accept payment in arrears or in kind. The medicine vendors are also easily accessible and provide cheap services as well. Prayers (by self, pastors/priests) are usually free of financial cost and often available on request. Therefore, it could be argued that those who presented to hospitals and health centres were those who did not benefit from the other treatment modalities. Agwu et.al¹⁷ had however revealed that the menopausal women (in their study in a rural community) considered the herbal therapies more effective than the treatment offered in the hospitals by orthodox health workers. It is necessary to identify the active agents in the herbal concoctions that relieve the women’s menopausal symptoms. It has previously been reported that the treatment of severe menopausal symptoms by most Nigerian Gynaecologists is suboptimal. Such treatment consists essentially of analgesics and anxiolytic agents. The author believes that more effective treatment of menopausal symptoms by orthodox healthcare providers in hospitals and health centres, including the use of HRT in appropriate cases, could improve the patronage of these facilities by women with menopausal symptoms.

It is concluded that Nigerian Igbo women experience most known menopausal symptoms and prefer herbal therapies for these symptoms. They have very low awareness of HRT.