INTRODUCTION

We live in an era where the population is ageing; more than 30% of women are aged 50 years of age and over. The menopause, from Greek word ‘MENOS’ (month) and ‘PAUSE’ (cessation), is defined as the last menstrual period. (1) The diagnosis can be made after a minimum of one year’s amenorrhea. Average age for menopause is 51 years (1).

In the literature, it has often been stated that it is a difficult period with many symptoms. (2) Besides being a major cause of morbidity, such as heart disease and osteoporosis, its hormonal changes also causes symptoms that affect the quality of life, such as hot flushes, night sweats, sleep disturbances, urinary frequency, vaginal dryness, poor memory, anxiety and depression. (3)

Menopausal symptoms can really have an important impact in the daily, social and sexual life of postmenopausal women. (4)

Hormone replacement therapy (HRT) is an effective treatment for menopausal symptoms and can protect women from developing osteoporosis, although its effectiveness is associated with continued use. (5)

It has been demonstrated that women’s attitudes towards the menopause and their knowledge of the benefits and risks of HRT have a direct effect on their use of HRT. (6) Osteoporosis causes no symptom until a fracture occurs. Dual-energy X-ray absorptiometry (DXA) instrument measures bone mineral density (BMD) at the spine and proximal femur. DXA is the preferred method for the diagnosis of osteoporosis and monitoring of BMD, changes over time.

The World Health Organization (WHO) diagnostic classification of BMD is based primarily on reference data obtained by DXA scan. (7)

According to the ISCD (International Society for Clinical Densitometry), indications for BMD testing include, women aged 65 yrs and older, Post menopausal women under 65 years with risk factors for osteoporosis and women discontinuing estrogen treatment..etc. (8)

The WHO classification of BMD into categories of normal (T-score: -1 or greater), osteopenia (T-score: between -1 and -2.5), osteoporosis (T-score: -2.5 or less), and severe osteoporosis (T-score: -2.5 or less with a fragility fracture), has been widely used since its introduction in 1994 (7)

The WHO classification is based on the T-score, with BMD values expressed as g/cm2    .

For the diagnosis of osteoporosis, posterior anterior (PA) view of spine and hip measured and site of lowest T-score is noted. (9)

The ISCD recommends that the WHO classification for diagnosis of osteoporosis is applied to postmenopausal women of all ethnicities and to men, aged 65 and older. (10)

The purpose of this study was to assess the knowledge and awareness of older women about menopause and its consequences and as well as, whether they had knowledge of women health care and management of menopause.

Now women live one-third of their lives after menopause and unfortunately, have a progressively declining quality of life. Maintenance of peri and post menopausal health is of paramount importance, in order to reduce the economic impact on society today and in near future.

MATERIAL & METHODS

A total of 73 women were included in the study. Their consent for participation in study was taken. For the collection of data specific Questionnaire was designed. Age of participants were 40 years and above. Data was collected during six months period by face to face interview and questionnaire filled by the investigator during the interview session.

Questionnaire was made up of 32 items and divided in 3 broad sections. 1st part included the women’s socio demographic characteristics, 2nd part included women’s current menstrual status and if menopausal, her experience of menopause and 3rd part included the awareness of menopause and its management like use of HRT and DXA scan, and BMD interpretations for the diagnosis of osteoporosis.

Independent variables were socio demographic data, age, marital status, parity, ethnicity, level of education and BMD values. Dependent variables were personal health care habits, life style and use of HRT. Most inquiries were recorded as Yes or No. Following the completion of questionnaire, height and weight were recorded to calculate BMI by using a specific formula as Weight (kg) / ht (m2)

Those women who were not aware of DXA scan for diagnosis of osteoporosis or those who were, but never underwent the scan, assessed for the risk of osteoporosis and sent to Radiology Department, Dow university Hospital for DXA scan of hip and spine. Women were asked to follow with the report. DXA scan reports were interpreted according to WHO classification of BMD.

Data was entered on computer by using SPSS version 14. Descriptive statistics were calculated, including mean, standard deviation. Chi-square test was used for qualitative variables and unpaired t-test for quantitative variables. A p-value of less than 0.05 was considered significant statistically.

RESULTS

The mean age of women was 46.2 years. Out of total, 55 (75.3%) women were housewives, 61 (83.6%) were married, 3(4.1%) were single and 8 (11%) were widow. Regarding the level of education 25 (32.4%) were graduate, 8 (11%) were post graduate, 9 (12.3%) were of intermediate level, 16 (21.9%) were metric and 15 (20.5%) were uneducated. If we discuss about ethnicity 54 (74%) women were Urdu speaking and remaining were belonged to others.

The mean age of menopause was 46.27+_5.04 years, 57(78.1%) women were postmenopausal, 11 (15.1%) were peri menopausal and 5(6.8%) were at premenopausal status. About 37(50.7%) women were aware of word menopause and the mostly seen sources were book 18 (24.7%), health care provider (GP) 10(13.7%) and friends 9(12.3%). Out of total, 22 (30.6%) women agreed that menopause is natural phenomenon, 10 (13.7%) considered it hormonal while, 31(42.5%) did not had knowledge of the reason of menopause.

In our study 61 (83.6%) women were satisfied with menopause and viewed it positive. Most of women said that ‘now they are free to have regular prayers and it is a natural phenomenon’. About 29 (39.7%) women cited that menopause should be treated while, only 10 (13.7%) of them were found aware of HRT and only 3 (4.1%) women were on HRT treatment.

Out of 73 women, 52 (71.2%) of women had natural menopause while, 8 (11%) had surgical menopause. Regarding the mode of menopause majority of them 24 (32.9%) had gradual decrease in flow with increased duration of cycle. In this study 38 (52.1%) women were sexually active and out of which 34 (46.6%) women had no problem in sexual activity. Out of total, 53 (72.6%) women believed that life style should be changed after menopause and most of women 26 (35.6%) believed that, activity, exercise, diet should be improved in this age.

Regarding osteoporosis, 52(71.2%) of women had awareness of osteoporosis and major source of awareness were GPs, 30 (41%). Only 15 (20.5%) women had their DXA scan done. On our referral to the Radiology Department for DXA scan, osteopenia was reported in 11 (15.1%) women, 10(13.7%) had normal scan but 51(70%) women had no follow up. Risks for Osteoporosis were also assessed, it was found that 29 (39.7%) of women had difficulty in raising from chair alone, 5(6.8%) had history of fractures, while 13(17.8%) had maternal history of fracture along with difficulty in raising from chair.

Statistically highly significant association was found between ‘level of education’ and ‘awareness of HRT’(X2=20.61, p= 0.000). Level of education was also highly associated reason of menopause (X2=50.86, p= 0.000). Statistically insignificant association seen between ‘awareness of HRT’ and ‘menopause needs treatment’(X2= 7.61 & p= 0.006). Level of education was not associated with views regarding menopause (X2= 1.997 & p= 0.736). Again there was no significant association seen between ‘ethnicity’ and ‘satisfaction with menopause’ (X2= 13.20 & p= 0.022).

Table 1

Sociedemographic characteristics

Table 2

Association between ‘menopause needs treatment’ versus ‘awareness of HRT’ (n =73)

Table 3

Association between ‘Women views about menopause’ versus ‘level of education’ (n =73)

Table 4

Association between ‘Knowledge of reason of menopause’ and ‘level of education’ (n =73)

DISCUSSION

Menopause is a natural phenomenon, so attention should be given to reproductive health in peri menopausal women. This study was an attempt to evaluate perception and awareness of menopause and its management. Around half of the participants were aware of word menopause in the present study, despite this fact that only few participants were aware of HRT therapy.

In this study mean age of women was 46.2 years. Study conducted by Dasgupta et al reported mean age of participant, 53.9 +_ 4.37 years, which is not consistent with present study and (11) mean age of menopause was 45.4 years. In another recently conducted study in Bangalore, mean menopausal age was 49.3 years. (12)

In similar studies conducted in urban area of Korea, Nigeria and India have shown, mean age of menopause 48.29, 49.8, 47.53 and 45.8 years respectively. (13-16) Mean age of menopause was 45.8 years in study conducted by Aarti K, which is consistent with our study. (16)

In our study, majority of women (84.3%) were married, 37.3% were graduate, 15.7% were postgraduate and 72.5% were postmenopausal. When we compared with study conducted by Aarti K, 89.8% participants were married, 44.8% were graduates, 22.5% were postgraduates and 59.6% were of postmenopausal age. (16)

In the present study, 34% women viewed it natural event and another 34% were not aware of reason of menopause. In study conducted by Ozumba BC et al on Nigerian women, 25% women considered menopause as natural event and viewed positive about it, but around 70% felt frustration after menopause. (17)

In a recent study conducted on Ghanaian women found that, around 53% women considered menopause as intricate part of life. Regarding the source of information this study showed that they listened about menopause from family members, friend and colleagues. Around 56% women learned about menopause from the women who experienced it. (18) These results are not consistent with our study, as 49% women were aware of word menopause and most common source of information was book, then health care provider and friends. According to study on Nigerian women, 66.8% women were aware of word menopause and most common source of information found book followed by friends and coworkers, which is consistent with our study. (14)

In the present study, 80% women were found not aware of HRT and just 5.9% were using them. These results were consistent with study conducted by Laydakis C et al, in which 78% women were not aware of HRT. According to that study, awareness level was lower in Indo-Asian women as compared to black and white women, but higher in age group of 50-59 years of age. (19) Another study conducted in Erbil City, showed that 93.4% menopausal women have heard about word menopause, 56.6% had prior knowledge of menopausal symptoms, 85.5% women perceived menopause as natural and 47% women considered it positive. In our study, 34% women considered cessation of menstruation a natural phenomenon, and 84.3% women viewed positive about it, that is not consistent with study conducted in Erbil City. (20)

In a study conducted in Hyderabad, reported that 78.79% women considered menopause as natural process, 83.4% women felt good after cessation of menses while 16.57% considered it negative. (21)

In a cross sectional study conducted in Shiraz, also reported positive attitude after menopause, (83.6%, now we will be not pregnant), (70.7%, we will able to involve more in community affairs). In same study, 41% women considered menopause as an unpleasant experience. (22) Other studies also showed positive attitude regarding menopause, 50.7% women considered it positive in the sense of freedom from monthly bleeding and inability to get pregnant. (3.4%)(14)

Awareness of word ‘osteoporosis’ was 62% in South Australian women, that was not consistent with our study in which 72% women were aware of osteoporosis.(23)

Another study conducted on rural Turkish women, in whom 60.8% of women had heard of and 44.9% knew the correct definition of osteoporosis. Television was the source of knowledge in 55% followed by doctors and nurses. In the present study GPs were the main source of awareness. (38%) (24)

CONCLUSION

Most of the women in this study were satisfied and viewed menopause positively. Majority of them said that menopause should be treated but fewer of them had the awareness of use of HRT. Most of them were aware of osteoporosis but never had DXA scan. Those who had DXA reports, more than half had Osteopenia.

RECOMMENDATION

We recommend that every woman of peri and postmenopausal age should have DXA scan for bone mineral density and even earlier if risk factors for osteoporosis are found.