CLIMACTERIC 2014;17:1–8
enopausal symptoms and quality of life in M Turkish women in the climacteric period B. Ceylan and N. Özerdoğan* Department of Fundamentals of Nursing, Ege University Faculty of Nursing, Bornova-Izmir; *Midwifery Department, Eskişehir High School Health, Eskisehir Osmangazi University, Eskişehir, Turkey Key words: MENOPAUSE, MENOPAUSAL SYMPTOMS, MENOPAUSE-SPECIFIC QUALITY OF LIFE (MENQOL) QUESTIONNAIRE
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ABSTRACT Objectives The purpose of this study is to determine the frequency of menopausal symptoms in Turkish women and the impact of these symptoms and related factors on the quality of life. Methods The sample in this cross-sectional study consisted of 1030 women, aged 40–59 years. The researcher collected the data at the women’s homes via the face-to-face interview method using the Menopause-Specific Quality of Life (MENQOL) questionnaire and a questionnaire developed and drawn up in line with the literature. Results The mean age (1 2 standard deviation) of the women participating in the study was 48.58 1 2 5.61 years and their mean menopausal age was 46.4 1 4.4 years. While the most frequently experienced menopau2 sal symptoms in the study were feeling tired and worn out (79.2%), aches in the muscles and joints (79.1%) and low backache (77.8%), the least experienced symptom was an increase in facial hair (28.3%). Significant differences were found between the subdomain mean scores on the MENQOL according to menopausal periods (p 0.000). Significant differences were detected in all subdomain mean scores of the MENQOL questionnaire according to age groups, perception of income, education, parity and body mass index (p 0.05). Conclusion In women in the climacteric period, the time that quality of life is the most affected among all the menopausal periods is the postmenopausal period. Women in menopause should not be forgotten; healthcare services addressing the health needs of women should not be restricted only to the period of fertility but continued with the same sensitivity throughout the life cycle.
INTRODUCTION Scientific and technological developments have caused an increase in the elderly world population by increasing the span of life1. According to the data listings (2012) of the world population, the expected life span for women in Turkey is 76 years2. According to the World Health Organization, menopause is the permanent termination of menstruation as a result of the cessation of ovarian activity3. Menopause is a portion of the climacteric period between the reproductive ages and old age. The climacteric period is characterized by a decrease in ovarian activity, a decline in probable fertility and the occurrence of various symptoms along with irregular intervals of
menstruation. The period encompasses a part of premenopause and the periods of perimenopause and postmenopause, up until old age4,5. The transition into menopause is related to different physical and mental changes that may affect women’s health6. Studies show that the physical, psychological, social and sexual changes in menopause have an adverse effect on women’s quality of life6–11. It has been expressed that 96% of women have menopausal complaints and their quality of life is affected not only physically and psychologically but also socially12. It is reported that the quality of life of women is especially adversely affected in the perimenopausal and early postmenopausal periods13.
Correspondence: Dr B. Ceylan, Department of Fundamentals of Nursing, Ege University Faculty of Nursing, Bornova-Izmir, Turkey; Email: ceylan4426@ gmail.com ORIGINAL ARTICLE © 2014 International Menopause Society DOI: 10.3109/13697137.2014.929108
Received 06-04-2014 Revised 02-05-2014 Accepted 21-05-2014
Menopausal symptoms and quality of life Together with the increasing prolongation of the expected life span, the time that is spent in the menopausal period is also increasing. Ensuring that women have a high quality of life in this period may be made possible by bringing out the problems they experience, together with related factors and determining the status of their quality of life. Although there are many studies that assess quality of life in different groups, studies related to the menopausal period are limited. This study aims at determining the frequency of menopausal symptoms in women, aged 40–59 years and the effects of their sociodemographic characteristics and other related factors on their quality of life.
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METHOD The study is of analytical and cross-sectional design and was conducted in the period April 2009–November 2009 in the town of Tepebaşı, Eskisehir in western Turkey. The study population consisted of 30 580 women between the ages of 40 and 59 years living in the town of Tepebaşı. The smallest sample size was calculated as 1030, where the frequency of menopausal symptoms was 50%, the margin of error was 1 2 3% and the confidence interval was 95%. The number of individuals to be recruited from each neighborhood was weighted based on the population ratios in the neighborhoods. The streets to be visited were determined according to a random number table. The study excluded women who had entered menopause due to surgery, were pregnant and/or breastfeeding, were using hormonal contraception or receiving hormone replacement treatment (HRT) or had received any other kind of hormonal treatment (such as hormonal treatment for thyroid disease) in the last 6 months. During data collection, 37 women using HRT or hormonal treatment/contraception and 59 women who had entered menopause due to surgery were not included in this study because they did not fulfil the study criteria. Of the women, 156 (15.0%) declined to participate in the study. The study was ultimately conducted with 874 women. The response rate was 85.0%. The data were collected by the researcher at the homes of the women, using the method of the face-to-face interview with a questionnaire that had been drawn up in line with the Menopause-Specific Quality of Life questionnaire (MENQOL) and the literature. The dependent variable of the study was the quality of life subdomain mean scores. Quality of life was assessed on the basis of the MENQOL questionnaire which was developed by Hilditch and colleagues14. The Turkish validity and reliability tests for the questionnaire were conducted by Kharbouch and S¸ahin. Cronbach a values were found to be 0.73 in the vasomotor domain, 0.84 in the psychosocial domain, 0.88 in the physical domain and 0.84 in the sexual domain7. The MENQOL questionnaire consists of 29 items divided into four domains: vasomotor (three items), psychosocial (seven items), physical (16 items) and sexual (three items). In line with the MENQOL questionnaire, at the data collection stage, the questions were formulated to receive ‘Yes’ or ‘No’
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Ceylan and Özerdoğan responses to queries about the women’s complaints in the last month. If the answer was ‘Yes’, the severity of the complaint was questioned on a scale of 0–6, with 0 signifying that the symptom was ‘not at all bothersome’ and 6 meaning that it was ‘extremely bothersome’. Prior to the analysis, each question was assigned points on a scale of 1–8, where 1 point meant that no problem had been experienced in the context of that item. The degree of severity of ‘0’ on the scale was converted to 2; ‘1’ point was converted to 3, ‘2’ points were converted to 4, ‘3’ points to 5, ‘4’ points to 6, ‘5’ points to 7, ‘6’ points to 8. The severity of the symptom increases as the score increases and low scores indicate a higher quality of life. This scale does not offer a general score and each subdomain is evaluated separately. Because the numbers of items in each subdomain are not equal, the mean scores in each subdomain were divided by the number of items in the subdomain and a re-calculation was performed to produce points of 1–86,8,14,15. The independent variables in the study were: age, marital status (‘unmarried’, “married’ and ‘widow/divorced/ separated’), educational status (‘illiterate’, ‘primary school’, ‘middle school’, ‘high school’, ‘university/college’), occupation (‘laborer’, ‘civil servant’ or ‘retired’ were classifications of the employed, ‘housewives’ were taken as unemployed), perception of income (‘my income is less than my expenditure’, ‘my income meets my expenditure/is more than my expenditure’), number of children (‘2 or less’, ‘3 or more’), perception of menopause (the responses ‘Positive’ or ‘Negative’ could be given to the question ‘What is your perception of the period of menopause?’), and body mass index (BMI). BMI was calculated by dividing weight in kilograms by height in meters squared. According to the classification of the World Health Organization, a BMI of 18.50 kg/m2 is considered underweight, 18.50–24.99 kg/m2 is normal, 25.00–29.99 kg/m2 is overweight and 30.00 kg/m2 is obese16. The periods of menopause were divided into premenopause (regular menstrual bleeding in the last 12 months), perimenopause (irregular menstrual bleeding in the last 12 months) and postmenopause (no menstrual bleeding in the last 12 months). The postmenopausal group was been further classified as a period of 5 years in postmenopause and a period 5 years in postmenopause6,7,10,17,18. The SPSS 15.0 statistics package program was used in the analysis of the data. Descriptive data are presented as numbers, percentages, means and standard deviations. The Mann–Whitney U-test was used to compare the quality of life subdomain mean scores in terms of two-category variables, while the Kruskal–Wallis one-way analysis of variance (ANOVA) test was used in variables with three or more categories. A p level of 0.05 was considered statistically significant. Wherever a significant difference was detected in the ANOVA, the Mann–Whitney U-test for multiple comparison was used as a post hoc test: The level of significance was then re-determined by dividing the significance level by the number in the group. The approval of the Ethics Board of the Eskisehir Osmangazi University Medical School was obtained and the required
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Menopausal symptoms and quality of life permission was received from the Eskisehir Provincial Directorate of Health. The verbal consent of the participants was additionally obtained.
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RESULTS The mean age of the study group was 48.58 1 2 5.61 years (Table 1). It was found that 54.6% of the women participating in the study had given birth once or twice; the average number of births per woman was 2.53 1 2 1.37 (maximum 10). The mean age at menopause of the women was 46.4 1 2 4.4 years (minimum age 30 years, maximum age 57 years) and the mean time since menopause was 6.34 1 2 4.35 years (minimum 1 year, maximum 20 years). In examining the frequency of experiencing menopausal symptoms, it was found that vasomotor and sexual symptoms were experienced more often by women who had been in the postmenopausal period 5 years; psychosocial symptoms were experienced more often by women who had been in the postmenopausal period for 5 years; physical symptoms were experienced more often by women who had been in the postmenopausal period, particularly for 5 years (Table 2). It was discovered that the symptoms most frequently experienced by women, when assessed in terms of the particular menopausal period, were low backache in the premenopausal period (74.1%); aches in back of neck or head in the perimenopausal period (82.2%); aching in muscles and joints in the postmenopausal for 5 years (83.7%); and feeling tired and worn out in the postmenopausal period of 5 years (88.2%) (Table 2). Among all of the symptoms, physical symptoms were the most frequently experienced in all of the periods of menopause. In an assessment of the periods of menopause as a whole, it was observed that feeling tired and worn out (79.2%), aching in muscles and joints (79.1%) and low backache (77.8%) were the most common symptoms experienced, while an increase in facial hair (28.3%) was the least common symptom. The difference between the MENQOL subdomain mean scores was found to be significant depending on the menopausal period (p 0.001) (Table 3). According to the post-hoc inter-group comparative analysis conducted for each subdomain, the highest mean scores were seen in the vasomotor and sexual domains in women who had been in the postmenopausal period for 5 years and in the psychosocial and physical domains in women who had been in the postmenopausal period for 5 years. In all subdomains, the mean scores of the women in the premenopausal period were detected to be significantly lower than the mean scores of the women in the other three periods; the physical domain mean scores of the women in the perimenopausal period were found to be significantly lower than the mean scores of the women who had been in the postmenopausal period for 5 years (p 0.000). Significant differences were detected in all MENQOL subdomains according to age groups (p 0.001); the highest mean scores were in the age group 55–59 years. It was observed that widows or divorced women had the highest
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Ceylan and Özerdoğan Table 1 Characteristics of the study group (n 874) Characteristics
n
%
Age group (years) 40–44 45–49 50–54 55–59
258 237 223 156
29.5 27.1 25.5 17.8
Marital status Unmarried Married Widow/divorced/separated
20 738 116
2.3 84.4 13.3
Educational status Illiterate Primary school Middle school High school University/college
62 496 116 136 64
7.1 56.8 13.3 15.6 7.3
Occupation Laborer Civil servant Retired Housewife
45 46 76 707
5.1 5.3 8.7 80.9
Perception of income Income expenditure Income expenditure Income expenditure
525 335 14
60.1 38.3 1.6
Parity 0 1–2 3–5 5
41 477 287 69
4.7 54.6 32.8 7.8
Menopause status Premenopause Perimenopause Postmenopause 5 years Postmenopause 5 years
355 107 166 246
40.6 12.2 19.0 28.1
Perception of menopause Positive Negative
341 533
39.0 61.0
significant mean scores in the vasomotor domain when compared to married women (p 0.007), also in the psychosocial domain when compared to both unmarried (p 0.008) and married (p 0.007) women and in the physical domain when compared to unmarried women (p 0.006). In all subdomains, the mean scores of uneducated women were significantly higher than the mean scores of women who had more education (p 0.000). The psychosocial (p 0.023) and physical (p 0.016) domain mean scores of working women were found to be significantly lower compared to unemployed women. The women with income that did not meet their
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Table 2 The percentage of the menopausal symptoms according to the menopausal period. Data are given as n (%) Premenopause (n 355)
Perimenopause (n 107)
Postmenopause 5 years (n 166)
Postmenopause 5 years (n 246)
Total (n 874)
Vasomotor Hot flushes or flashes Night sweats Sweating
130 (36.6) 110 (31.0) 122 (34.4)
70 (65.4) 58 (54.2) 56 (52.3)
127 (76.5) 106 (63.9) 116 (69.9)
159 (64.6) 144 (58.5) 159 (64.6)
486 (55.6) 418 (47.8) 453 (51.8)
Psychosocial Being dissatisfied with my personal life Feeling anxious or nervous Experiencing poor memory Accomplishing less than I used to Feeling depressed, down or blue Being impatient with other people Feelings of wanting to be alone
122 194 226 152 161 122 157
(34.4) (54.6) (63.7) (42.8) (45.4) (34.4) (44.2)
41 76 74 57 74 57 52
(38.3) (71.0) (69.2) (53.3) (69.2) (53.3) (48.6)
78 101 131 98 95 81 94
(47.0) (60.8) (78.9) (59.0) (57.2) (48.8) (56.6)
121 163 206 148 146 121 125
(49.2) (66.3) (83.7) (60.2) (59.3) (49.2) (50.8)
362 534 637 455 476 381 428
(41.4) (61.1) (72.9) (52.1) (54.5) (43.6) (49.0)
Physical Flatulence or gas pains Aching in muscles and joints Feeling tired or worn out Difficulty sleeping Aches in back of neck or head Decrease in physical strength Decrease in stamina Feeling a lack of energy Drying skin Weight gain Increased facial hair Changes in appearance, texture or tone of skin Feeling bloated Low backache Frequent urination Involuntary urination when laughing/coughing
151 256 262 149 252 196 195 212 124 166 69 89 205 263 141 103
(42.5) (72.1) (73.8) (42.0) (71.0) (55.2) (54.9) (59.7) (34.9) (46.8) (19.4) (25.1) (57.7) (74.1) (39.7) (29.0)
46 87 81 57 88 66 67 76 49 62 32 34 68 82 56 44
(43.0) (81.3) (75.7) (53.3) (82.2) (61.7) (62.6) (71.0) (45.8) (57.9) (29.9) (31.8) (63.6) (76.6) (52.3) (41.1)
92 139 132 102 126 119 109 125 75 104 58 67 112 132 99 92
(55.4) (83.7) (79.5) (61.4) (75.9) (71.7) (65.7) (75.3) (45.2) (62.7) (34.9) (40.4) (67.5) (79.5) (59.6) (55.4)
152 209 217 149 200 192 177 191 130 150 88 97 152 203 140 129
(61.8) (85.0) (88.2) (60.6) (81.3) (78.0) (72.0) (77.6) (52.8) (61.0) (35.8) (39.4) (61.8) (82.5) (56.9) (52.4)
441 691 692 457 666 573 548 604 378 482 247 287 537 680 436 368
(50.5) (79.1) (79.2) (52.3) (76.2) (65.6) (62.7) (69.1) (43.2) (55.1) (28.3) (32.8) (61.4) (77.8) (49.9) (42.1)
Sexual Change in your sexual desire Vaginal dryness during intercourse Avoiding intimacy
(n 322) 73 (22.7) 71 (22.0) 79 (24.5)
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Symptom
expenditure, those at normal weight and those that had given birth three times or more had significantly lower mean scores in all subdomains (p 0.05). The women who had a negative perception of the period of the menopause had significantly higher mean scores in the vasomotor domain compared to women with positive perceptions (p 0.05) (Table 4).
DISCUSSION This study examined the impact of symptom frequency, sociodemographic characteristics and other related factors on the quality of life in the menopausal period. The transition from the period of fertility to the period of decreasing ovarian func-
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(n 91) 38 (41.8) 35 (38.5) 43 (47.3)
(n 139) 69 (49.6) 64 (46.0) 70 (50.4)
(n 186) 70 (37.6) 66 (35.5) 79 (42.5)
(n 740) 252 (34.1) 238 (32.2) 273 (36.9)
tion is a gradual process. For this reason, it is difficult to ascertain a definite age for menopause inception in any woman. This period usually starts at the age of 40 years, varying from one woman to another. The distribution of menopausal age incidence in population-based studies is expressed in a bell-shaped curve that starts around the age of 40 and ends at approximately age 54; the age of menopause is generally seen to vary between the ages of 45 and 55 years8–11,15,17–23. According to the results of various studies conducted in Turkey, the average age of menopause varies between ages 45 and 501,24–28. In the present study, the mean age of menopause was found to be 46.4 1 2 4.4 years. Studies report that physical symptoms are more frequently experienced when compared to symptoms in other
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Table 3 Mean scores on MENQOL questionnaire subdomain according to menopausal periods. Data are given as mean 1 2 standard deviation Quality of life score
Menopausal period
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Premenopause Perimenopause Postmenopause 5 years Postmenopause 5 years p Value
Vasomotor (n 874) 2.28 1 2 1.76 3.58 1 2 2.12 4.19 1 2 2.19 3.92 1 2 2.23 0.000
domains8,18–20,29. Our study also supports this. In our study, the vasomotor symptoms were more frequently seen in women who had been in the postmenopausal period for 5 years. The study of Bairy and colleagues reports that women who have been in menopause for 3.5 years experience vasomotor symptoms more frequently29. Various studies indicate that postmenopausal women of 5 years18, perimenopausal 8 women , peri- and postmenopausal women9,17 experience vasomotor symptoms more frequently. In studies, the rate of ‘hot flushes’ in the premenopausal period is between 16.66% and 31.7%; according to our study, it has a lower rate8–10,17. In our study, the mean menopausal age of the women was 46.4 1 2 4.4 years; the mean age of the women in the premenopausal period was 44.4 1 2 3.5 years. This result may be explained by the fact that the frequency of the ‘hot flushes’ symptom was higher in the women in the premenopausal period due to the mean age of these women being close to the mean age of menopause. Our study, consistent with the other studies on psychosocial symptoms, found that these complaints were more frequently experienced in the perimenopausal period and in postmenopausal women who had been in this period for 5 years8,9,17,18. The symptoms in the sexual domain were more frequently experienced by women who had been in postmenopause for 5 years compared to the women in the other groups. The studies conducted also show that postmenopausal women more frequently experience symptoms in the sexual domain when compared to women in pre- and perimenopause8–10. In a study by Poomalar, women in the postmenopausal period experienced all symptoms more frequently when compared with the pre- and perimenopausal women18. When the entire group is taken into consideration, the most frequently experienced symptoms in our study were ‘feeling tired and worn out’ (79.2%), ‘aching in muscles and joints’ (79.1%) and ‘low backache’ (77.8%). There are studies with results similar to our study findings8,17,18,20,29. There are also studies in which the most frequently experienced symptoms have been reported to be ‘experiencing poor memory’ (84.1%)19 and ‘hot flushes’ (79.6%)1. The least commonly experienced symptom in our study was ‘increased facial hair’ (28.3%). While there are studies reporting findings similar to ours1,17,29, there are other studies that have
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Psychosocial (n 874) 2.61 1 2 1.48 3.05 1 2 1.27 3.23 1 2 1.65 3.56 1 2 1.75 0.000
Physical (n 874)
Sexual (n 738)
2.93 1 2 1.28 3.35 1 2 1.16 3.66 1 2 1.42 3.98 1 2 1.46 0.000
1.88 1 2 1.70 2.66 1 2 1.98 3.22 1 2 2.55 2.90 1 2 2.50 0.000
found ‘being dissatisfied with my personal life’8,20, ‘night sweats’10 and ‘vaginal dryness during intercourse’18 to be the least frequently experienced symptoms. In our study, the highest mean scores were exhibited in the vasomotor and physical domains by women who had been in postmenopause for 5 years and in the psychosocial and physical domains by women who had been in postmenopause for 5 years. While there are studies in the literature that indicate, similar to our study, that postmenopausal women exhibit the highest mean scores on all of the subdomains of the MENQOL questionnaire7,19, there are also studies that report that perimenopausal women exhibit the highest mean scores in the vasomotor, psychosocial and physical domains and that postmenopausal women have the highest mean scores in the sexual domain8,10. Som and Ray have asserted that, as the duration of the menopause increases, the mean scores in the vasomotor domain decrease (p 0.001) while mean scores in the psychosocial, physical and sexual domains increase significantly (p 0.05)11. In our study, the women with the lowest mean scores in all subdomains were in the age group 40–44 years (p 0.001). In a study conducted by Williams and colleagues, the lowest mean scores were found to be in the age group 60–6515. Fallahzadeh’s study reports lowest scores in women aged 60–65 years in the vasomotor domain and in the 45–49-year age group in the psychosocial, physical and sexual domains6. Our study did not evaluate the subdomain of sexuality in the group of unmarried women since sexuality out of marriage is an unwelcome and rare occurrence in Turkish society. It was discovered that widowed or divorced women had the significantly highest mean scores in all subdomains (except for sexuality) (p 0.001). This finding suggests that widowed or divorced women lack the support mechanisms they need as a result of prejudice and social isolation in Turkish society which causes them therefore to experience menopausal symptoms more intensely. Hafız and colleagues found in their study that women with no partners tended to have significantly lower mean scores in the physical and sexual domains compared to women who did have partners (p 0.05)20. In the study of Ghazanfarpour and colleagues, unmarried women, as in our study, had the lowest mean scores in all subdomains (except in the sexual domain)30. The uneducated women in
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Table 4 Mean scores on MENQOL questionnaire subdomain according to women’s characteristics. Data are given as mean 1 2 standard deviation Quality of life score
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Characteristics
Vasomotor (n 874)
Psychosocial (n 874)
Physical (n 874)
Sexual (n 738)
Age group (years) 40–44 45–49 50–54 55–59 p Value
2.24 1 2 1.74 3.34 1 2 2.21 3.85 1 2 2.15 4.03 1 2 2.24 0.000
2.62 1 2 1.50 3.05 1 2 1.54 3.15 1 2 1.55 3.60 1 2 1.84 0.000
2.84 1 2 1.28 3.40 1 2 1.32 3.54 1 2 1.27 4.22 1 2 1.53 0.000
1.83 1 2 1.66 2.57 1 2 2.15 2.78 1 2 2.33 3.26 1 2 2.69 0.000
Marital status Unmarried Married Widow/divorced/separated p Value
2.60 1 2 1.92 3.21 1 2 2.20 3.73 1 2 2.10 0.011
2.55 1 2 1.71 2.99 1 2 1.60 3.49 1 2 1.64 0.001
2.66 1 2 1.18 3.39 1 2 1.38 3.70 1 2 1.57 0.014
* 2.49 1 2 2.20 * *
Educational status Illiterate Primary school Middle school High school University/college p Value
4.69 1 2 2.13 3.41 1 2 2.21 2.72 1 2 1.86 2.91 1 2 2.13 2.57 1 2 2.01 0.000
4.12 1 2 1.71 3.20 1 2 1.62 2.74 1 2 1.49 2.44 1 2 1.41 2.65 1 2 1.45 0.000
4.41 1 2 1.43 3.49 1 2 1.37 3.16 1 2 1.49 3.10 1 2 1.31 2.99 1 2 1.31 0.000
3.34 1 2 2.62 2.56 1 2 2.19 2.34 1 2 2.25 2.05 1 2 1.97 2.35 1 2 2.05 0.009
Occupational status Working Not working p Value
3.03 1 2 2.13 3.32 1 2 2.20 0.117
2.76 1 2 1.43 3.12 1 2 1.65 0.023
3.17 1 2 1.38 3.47 1 2 1.42 0.016
2.38 1 2 2.25 2.51 1 2 2.19 0.376
Perception of income Income expenses Income expenses p Value
3.00 1 2 2.08 3.65 1 2 2.28 0.000
2.79 1 2 1.48 3.42 1 2 1.74 0.000
3.18 1 2 1.31 3.76 1 2 1.49 0.000
2.26 1 2 2.00 2.82 1 2 2.43 0.007
Body mass index (kg/m2) 18.5 (underweight) 18.5–24.99 (normal) 25.00–29.99 ( overweight) 30 (obese) p Value
3.19 1 2 2.50 2.88 1 2 2.09 3.29 1 2 2.15 3.57 1 2 2.27 0.004
3.52 1 2 1.59 2.86 1 2 1.65 3.02 1 2 1.54 3.22 1 2 1.69 0.033
3.32 1 2 0.82 3.12 1 2 1.43 3.39 1 2 1.41 3.71 1 2 1.38 0.000
3.62 1 2 2.51 2.21 1 2 2.07 2.66 1 2 2.27 2.43 1 2 2.17 0.023
Parity 2 3 p Value
3.46 1 2 2.26 2.97 1 2 2.04 0.002
3.33 1 2 1.63 2.62 1 2 1.50 0.000
3.57 1 2 1.47 3.18 1 2 1.30 0.000
2.76 1 2 2.34 2.10 1 2 1.93 0.000
Perception of menopause Positive Negative p Value
3.01 1 2 2.07 3.43 1 2 2.25 0.007
3.01 1 2 1.59 3.07 1 2 1.64 0.691
3.39 1 2 1.46 3.43 1 2 1.39 0.462
2.36 1 2 2.11 2.57 1 2 2.26 0.220
*, Only married women were assessed
our study exhibited the highest mean scores in all subdomains. There are studies that support this finding1,7,9,17,30. Having an education makes a positive contribution to women’s lives in that they attain a higher level of income and opportunities.
6
The higher quality of life of educated women, as opposed to the uneducated, may be explained by the fact that these women are more easily able to reach the knowledge, support and services they need with respect to their health. While in
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Menopausal symptoms and quality of life Fallahzadeh’s study women who were university graduates exhibited the highest mean scores in the vasomotor domain, they revealed the lowest mean scores in the psychosocial, physical and sexual domains6. In our study, the housewives who were classified as the unemployed group were seen to have significantly higher scores in the psychosocial and physical domains (p 0.05). In the study of Som and Ray, working women had higher scores in the vasomotor area while unemployed women had significantly higher scores in the psychosocial, physical and sexual domains (p 0.05)11. In our study, the women whose income was lower than their expenditure had significantly lower mean scores in all subdomains (p 0.05). In Poomalar’s study, it was seen that women with a monthly income of 5000Rs experience all the subdomain symptoms less18. In the study of Fallahzadeh, women with higher levels of income had lower mean scores in the psychosocial and physical areas (p 0.05)6. Our study revealed that obese women had the highest scores in the vasomotor and physical domains whereas underweight women had the highest scores in the psychosocial and sexual domains. Studies indicate that, as BMI increases, all sub domain mean scores on the MENQOL increase and quality of life suffers9,15,20,30.
CONCLUSION When the female population in the climacteric period of life is considered together with the menopausal complaints experienced in this period, it can be said that menopause is an important societal issue. In women living through the climacteric period, the postmenopausal period is the part of the cycle
Ceylan and Özerdoğan that most commonly has an impact on the quality of life. Within the postmenopausal period itself, while vasomotor and sexual domains of life are most adversely affected in the first 5 years, the psychosocial and physical areas are more commonly affected in women who have been in postmenopause for 5 years. Factors such as having a higher level of education, working and having a normal weight have a positive effect on quality of life. For women to have a better quality of life, policies that will address the needs of women in all of their life cycles need to be adopted and sustained with sensitivity so that support can be provided, both socially and in health services.
Limitations This study has a few limitations. First, the study is of crosssectional design. Only relationships have been defined between the domains of quality of life and the independent variables in the study. The examination of causal relationships is weak. There is, therefore, a need for a cohort study with follow-up to be able to show the effects of independent variables on the quality of life. Second, because responses about symptoms in the sexual domain came only from married women, the quality of life of the other women in terms of sexuality could not be explored. Conflict of interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper. Source of funding Nil.
References 1. Yanıkkerem E, Koltan SO, Tamay AG, Dikayak Ş. Relationship between women’s attitude towards menopause and quality of life. Climacteric 2012;15:552–62 2. Population Reference Bureau, 2012 World Population Data Sheet. Access date: 10 Sept, 2013. Available from: http://www. prb.org/pdf12/2012-population-data-sheet_eng.pdf 3. Avraham Y, Nachum S. Management of obesity in menopause: lifestyle modification, medication, bariatric surgery and personalized treatment. In Volodymyr Dvornyk, ed. Current Topics in Menopause Oak Park, Il, USA: Bentham Science, 2013:143–62 4. Özkan S. Climacterium and Menopause. In Şirin A, Kavlak O, eds. Turk Women’s Health Book. Istanbul: Bedray Publishing, 2008:234–58 5. Doubova SV, Espinosa-Alarcón P, Flores-Hernández S, Infante C, Pérez-Cuevas R. Integrative health care model for climacteric stage women: design of the intervention. BMC Women’s Health 2011;11:6–15 6. Fallahzadeh H. Quality of life after the menopause in Iran: A population study. Qual Life Res 2010;19:813–19 7. Kharbouch SB, Şahin NH. Determination of the quality of life during menopausal stages. Turk J Istanbul University Florence Nightingale School of Nursing 2007;15:82–90
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8. Syed Alwi SA, Lee PY, Awi I, Malik PS, Haizal MN. The menopausal experience among indigenous women of Sarawak, Malaysia. Climacteric 2009;16:548–56 9. Lu J, Liu J, Eden J. The experience of menopausal symptoms by Arabic women in Sydney. Climacteric 2007;10:72–9 10. Peeyananjarassri K, Cheewadhanaraks S, Hubbard M, Zoa Manga R, Manocha R, Eden J. Menopausal symptoms in a hospital-based sample of women in southern Thailand. Climacteric 2006;9:23–9 11. Som N, Ray S. Menopause-specific quality of life of urban women in West Bengal, India. Menopause Int 2012;18:99–105 12. Guimarães A, Baptista F. Influence of habitual physical activity on the symptoms of climacterium/menopause and the quality of life of middle-aged women. Int J Women’s Health 2011;3:319–28 13. Shin H, Shin HS. Measurement of quality of life in menopausal women: A systematic review. West J Nurs Res 2012;34: 475–503 14. Hilditch JR, Lewis J, Peter A, et al. A menopause-specific quality of life questionnaire: development and psychometric properties. Maturitas 1996;24:161–75 15. Williams RE, Levine KB, Kalilani L, Lewis J, Clark RW. Menopause-specific questionnaire assessment in US population-based
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Menopausal symptoms and quality of life study shows negative impact on health-related quality of life. Maturitas 2009;62:153–9 16. World Health Organization Global Database on Body Mass Index. Access date:15 Feb, 2014. Available from: http://apps. who.int/bmi/index.jsp?introPage intro3.html 17. Liu J, Eden J. Experience and attitudes toward menopause in Chinese women living in Sydney – a cross sectional survey. Maturitas 2007;58:359–65 18. Poomalar GK, Arounassalame B. The quality of life during and after menopause among rural women. J Clin Diagn Res 2013;7:135–9 19. Chen Y, Lın S-Q, Wei Y, Gao H-L, Wu Z-L. Menopause-specific quality of life satisfaction in community-dwelling menopausal women in China. Gynecol Endocrinol 2007;23:166–72 20. Hafız I, Liu J, Eden J. A quantitative analysis of the menopause experience of Indian women living in Sydney. Aust N Z J Obstet Gynaecol 2007;47:329–34 21. Waidyasekera H, Wijewardena K, Lindmark G, Naessen T. Menopausal symptoms and quality of life during the menopausal transition in Sri Lankan women. Menopause 2009;16:164–70 22. Borker SA, Venugopalan PP, Bhat SN. Study of menopausal symptoms and perceptions about menopause among women at a rural community in Kerala. J Mid-life Health 2013;4:182–7 23. Palacios S, Henderson VW, Siseles N, Tan D, Villaseca P. Age of menopause and impact of climacteric symptoms by geographical region. Climacteric 2010;13:419–28
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Ceylan and Özerdoğan 24. Çoban A, Nehir S, Özbaşaran F, İnceboz Ü. The impact on meno pausal symptoms of marital adjustment and attitude toward menopausal of married women in the climacteric period. Turk Firat University Med J Health Sciences 2008;22:343–9 25. Budakoğlu İ, Özcan C, Eroğlu D, Yanık F. Quality of life and postmenopausal symptoms among women in a rural district of the capital city of the Turkey. Gynecol Endocrinol 2007; 23:404–9 26. Tokuç B, Kaplan PB, Balık GÖ, Gül H. Quality of life among women who were attending to Trakya University Hospital Menopause clinic. J Turk Soc Obstet Gynecol 2006; 3:281–7 27. Çaylan A, Aydemir I, Dağdeviren N, et al. Assessment of health related quality of life among perimenopausal Turkish women. HealthMED 2011;5:741–52 28. Aydın ZD, Erbaş B, Karakuş N, Aydın O, Özkan ŞK. Sun exposure and age at natural menopause: A cross-sectional study in Turkish women. Maturitas 2005;52:235–48 29. Bairy L, Adiga S, Bhat P, Bhat R. Prevalence of menopausal symptoms and quality of life after menopause in women from South India. Aust N Z J Obstet Gynaecol 2009;49:106–9 30. Ghazanfarpour M, Abdolahian S, Zare M, Shahsavari S. Association between anthropometric indices and quality of life in menopausal women. Gynecol Endocrinol 2013;29: 917–20
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enopausal symptoms and quality of life in M Turkish women in the climacteric period B. Ceylan and N. Özerdoğan* Department of Fundamentals of Nursing, Ege University Faculty of Nursing, Bornova-Izmir; *Midwifery Department, Eskişehir High School Health, Eskisehir Osmangazi University, Eskişehir, Turkey Key words: MENOPAUSE, MENOPAUSAL SYMPTOMS, MENOPAUSE-SPECIFIC QUALITY OF LIFE (MENQOL) QUESTIONNAIRE
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ABSTRACT Objectives The purpose of this study is to determine the frequency of menopausal symptoms in Turkish women and the impact of these symptoms and related factors on the quality of life. Methods The sample in this cross-sectional study consisted of 1030 women, aged 40–59 years. The researcher collected the data at the women’s homes via the face-to-face interview method using the Menopause-Specific Quality of Life (MENQOL) questionnaire and a questionnaire developed and drawn up in line with the literature. Results The mean age (1 2 standard deviation) of the women participating in the study was 48.58 1 2 5.61 years and their mean menopausal age was 46.4 1 4.4 years. While the most frequently experienced menopau2 sal symptoms in the study were feeling tired and worn out (79.2%), aches in the muscles and joints (79.1%) and low backache (77.8%), the least experienced symptom was an increase in facial hair (28.3%). Significant differences were found between the subdomain mean scores on the MENQOL according to menopausal periods (p 0.000). Significant differences were detected in all subdomain mean scores of the MENQOL questionnaire according to age groups, perception of income, education, parity and body mass index (p 0.05). Conclusion In women in the climacteric period, the time that quality of life is the most affected among all the menopausal periods is the postmenopausal period. Women in menopause should not be forgotten; healthcare services addressing the health needs of women should not be restricted only to the period of fertility but continued with the same sensitivity throughout the life cycle.
INTRODUCTION Scientific and technological developments have caused an increase in the elderly world population by increasing the span of life1. According to the data listings (2012) of the world population, the expected life span for women in Turkey is 76 years2. According to the World Health Organization, menopause is the permanent termination of menstruation as a result of the cessation of ovarian activity3. Menopause is a portion of the climacteric period between the reproductive ages and old age. The climacteric period is characterized by a decrease in ovarian activity, a decline in probable fertility and the occurrence of various symptoms along with irregular intervals of
menstruation. The period encompasses a part of premenopause and the periods of perimenopause and postmenopause, up until old age4,5. The transition into menopause is related to different physical and mental changes that may affect women’s health6. Studies show that the physical, psychological, social and sexual changes in menopause have an adverse effect on women’s quality of life6–11. It has been expressed that 96% of women have menopausal complaints and their quality of life is affected not only physically and psychologically but also socially12. It is reported that the quality of life of women is especially adversely affected in the perimenopausal and early postmenopausal periods13.
Correspondence: Dr B. Ceylan, Department of Fundamentals of Nursing, Ege University Faculty of Nursing, Bornova-Izmir, Turkey; Email: ceylan4426@ gmail.com ORIGINAL ARTICLE © 2014 International Menopause Society DOI: 10.3109/13697137.2014.929108
Received 06-04-2014 Revised 02-05-2014 Accepted 21-05-2014
Menopausal symptoms and quality of life Together with the increasing prolongation of the expected life span, the time that is spent in the menopausal period is also increasing. Ensuring that women have a high quality of life in this period may be made possible by bringing out the problems they experience, together with related factors and determining the status of their quality of life. Although there are many studies that assess quality of life in different groups, studies related to the menopausal period are limited. This study aims at determining the frequency of menopausal symptoms in women, aged 40–59 years and the effects of their sociodemographic characteristics and other related factors on their quality of life.
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METHOD The study is of analytical and cross-sectional design and was conducted in the period April 2009–November 2009 in the town of Tepebaşı, Eskisehir in western Turkey. The study population consisted of 30 580 women between the ages of 40 and 59 years living in the town of Tepebaşı. The smallest sample size was calculated as 1030, where the frequency of menopausal symptoms was 50%, the margin of error was 1 2 3% and the confidence interval was 95%. The number of individuals to be recruited from each neighborhood was weighted based on the population ratios in the neighborhoods. The streets to be visited were determined according to a random number table. The study excluded women who had entered menopause due to surgery, were pregnant and/or breastfeeding, were using hormonal contraception or receiving hormone replacement treatment (HRT) or had received any other kind of hormonal treatment (such as hormonal treatment for thyroid disease) in the last 6 months. During data collection, 37 women using HRT or hormonal treatment/contraception and 59 women who had entered menopause due to surgery were not included in this study because they did not fulfil the study criteria. Of the women, 156 (15.0%) declined to participate in the study. The study was ultimately conducted with 874 women. The response rate was 85.0%. The data were collected by the researcher at the homes of the women, using the method of the face-to-face interview with a questionnaire that had been drawn up in line with the Menopause-Specific Quality of Life questionnaire (MENQOL) and the literature. The dependent variable of the study was the quality of life subdomain mean scores. Quality of life was assessed on the basis of the MENQOL questionnaire which was developed by Hilditch and colleagues14. The Turkish validity and reliability tests for the questionnaire were conducted by Kharbouch and S¸ahin. Cronbach a values were found to be 0.73 in the vasomotor domain, 0.84 in the psychosocial domain, 0.88 in the physical domain and 0.84 in the sexual domain7. The MENQOL questionnaire consists of 29 items divided into four domains: vasomotor (three items), psychosocial (seven items), physical (16 items) and sexual (three items). In line with the MENQOL questionnaire, at the data collection stage, the questions were formulated to receive ‘Yes’ or ‘No’
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Ceylan and Özerdoğan responses to queries about the women’s complaints in the last month. If the answer was ‘Yes’, the severity of the complaint was questioned on a scale of 0–6, with 0 signifying that the symptom was ‘not at all bothersome’ and 6 meaning that it was ‘extremely bothersome’. Prior to the analysis, each question was assigned points on a scale of 1–8, where 1 point meant that no problem had been experienced in the context of that item. The degree of severity of ‘0’ on the scale was converted to 2; ‘1’ point was converted to 3, ‘2’ points were converted to 4, ‘3’ points to 5, ‘4’ points to 6, ‘5’ points to 7, ‘6’ points to 8. The severity of the symptom increases as the score increases and low scores indicate a higher quality of life. This scale does not offer a general score and each subdomain is evaluated separately. Because the numbers of items in each subdomain are not equal, the mean scores in each subdomain were divided by the number of items in the subdomain and a re-calculation was performed to produce points of 1–86,8,14,15. The independent variables in the study were: age, marital status (‘unmarried’, “married’ and ‘widow/divorced/ separated’), educational status (‘illiterate’, ‘primary school’, ‘middle school’, ‘high school’, ‘university/college’), occupation (‘laborer’, ‘civil servant’ or ‘retired’ were classifications of the employed, ‘housewives’ were taken as unemployed), perception of income (‘my income is less than my expenditure’, ‘my income meets my expenditure/is more than my expenditure’), number of children (‘2 or less’, ‘3 or more’), perception of menopause (the responses ‘Positive’ or ‘Negative’ could be given to the question ‘What is your perception of the period of menopause?’), and body mass index (BMI). BMI was calculated by dividing weight in kilograms by height in meters squared. According to the classification of the World Health Organization, a BMI of 18.50 kg/m2 is considered underweight, 18.50–24.99 kg/m2 is normal, 25.00–29.99 kg/m2 is overweight and 30.00 kg/m2 is obese16. The periods of menopause were divided into premenopause (regular menstrual bleeding in the last 12 months), perimenopause (irregular menstrual bleeding in the last 12 months) and postmenopause (no menstrual bleeding in the last 12 months). The postmenopausal group was been further classified as a period of 5 years in postmenopause and a period 5 years in postmenopause6,7,10,17,18. The SPSS 15.0 statistics package program was used in the analysis of the data. Descriptive data are presented as numbers, percentages, means and standard deviations. The Mann–Whitney U-test was used to compare the quality of life subdomain mean scores in terms of two-category variables, while the Kruskal–Wallis one-way analysis of variance (ANOVA) test was used in variables with three or more categories. A p level of 0.05 was considered statistically significant. Wherever a significant difference was detected in the ANOVA, the Mann–Whitney U-test for multiple comparison was used as a post hoc test: The level of significance was then re-determined by dividing the significance level by the number in the group. The approval of the Ethics Board of the Eskisehir Osmangazi University Medical School was obtained and the required
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Menopausal symptoms and quality of life permission was received from the Eskisehir Provincial Directorate of Health. The verbal consent of the participants was additionally obtained.
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RESULTS The mean age of the study group was 48.58 1 2 5.61 years (Table 1). It was found that 54.6% of the women participating in the study had given birth once or twice; the average number of births per woman was 2.53 1 2 1.37 (maximum 10). The mean age at menopause of the women was 46.4 1 2 4.4 years (minimum age 30 years, maximum age 57 years) and the mean time since menopause was 6.34 1 2 4.35 years (minimum 1 year, maximum 20 years). In examining the frequency of experiencing menopausal symptoms, it was found that vasomotor and sexual symptoms were experienced more often by women who had been in the postmenopausal period 5 years; psychosocial symptoms were experienced more often by women who had been in the postmenopausal period for 5 years; physical symptoms were experienced more often by women who had been in the postmenopausal period, particularly for 5 years (Table 2). It was discovered that the symptoms most frequently experienced by women, when assessed in terms of the particular menopausal period, were low backache in the premenopausal period (74.1%); aches in back of neck or head in the perimenopausal period (82.2%); aching in muscles and joints in the postmenopausal for 5 years (83.7%); and feeling tired and worn out in the postmenopausal period of 5 years (88.2%) (Table 2). Among all of the symptoms, physical symptoms were the most frequently experienced in all of the periods of menopause. In an assessment of the periods of menopause as a whole, it was observed that feeling tired and worn out (79.2%), aching in muscles and joints (79.1%) and low backache (77.8%) were the most common symptoms experienced, while an increase in facial hair (28.3%) was the least common symptom. The difference between the MENQOL subdomain mean scores was found to be significant depending on the menopausal period (p 0.001) (Table 3). According to the post-hoc inter-group comparative analysis conducted for each subdomain, the highest mean scores were seen in the vasomotor and sexual domains in women who had been in the postmenopausal period for 5 years and in the psychosocial and physical domains in women who had been in the postmenopausal period for 5 years. In all subdomains, the mean scores of the women in the premenopausal period were detected to be significantly lower than the mean scores of the women in the other three periods; the physical domain mean scores of the women in the perimenopausal period were found to be significantly lower than the mean scores of the women who had been in the postmenopausal period for 5 years (p 0.000). Significant differences were detected in all MENQOL subdomains according to age groups (p 0.001); the highest mean scores were in the age group 55–59 years. It was observed that widows or divorced women had the highest
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Ceylan and Özerdoğan Table 1 Characteristics of the study group (n 874) Characteristics
n
%
Age group (years) 40–44 45–49 50–54 55–59
258 237 223 156
29.5 27.1 25.5 17.8
Marital status Unmarried Married Widow/divorced/separated
20 738 116
2.3 84.4 13.3
Educational status Illiterate Primary school Middle school High school University/college
62 496 116 136 64
7.1 56.8 13.3 15.6 7.3
Occupation Laborer Civil servant Retired Housewife
45 46 76 707
5.1 5.3 8.7 80.9
Perception of income Income expenditure Income expenditure Income expenditure
525 335 14
60.1 38.3 1.6
Parity 0 1–2 3–5 5
41 477 287 69
4.7 54.6 32.8 7.8
Menopause status Premenopause Perimenopause Postmenopause 5 years Postmenopause 5 years
355 107 166 246
40.6 12.2 19.0 28.1
Perception of menopause Positive Negative
341 533
39.0 61.0
significant mean scores in the vasomotor domain when compared to married women (p 0.007), also in the psychosocial domain when compared to both unmarried (p 0.008) and married (p 0.007) women and in the physical domain when compared to unmarried women (p 0.006). In all subdomains, the mean scores of uneducated women were significantly higher than the mean scores of women who had more education (p 0.000). The psychosocial (p 0.023) and physical (p 0.016) domain mean scores of working women were found to be significantly lower compared to unemployed women. The women with income that did not meet their
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Ceylan and Özerdoğan
Table 2 The percentage of the menopausal symptoms according to the menopausal period. Data are given as n (%) Premenopause (n 355)
Perimenopause (n 107)
Postmenopause 5 years (n 166)
Postmenopause 5 years (n 246)
Total (n 874)
Vasomotor Hot flushes or flashes Night sweats Sweating
130 (36.6) 110 (31.0) 122 (34.4)
70 (65.4) 58 (54.2) 56 (52.3)
127 (76.5) 106 (63.9) 116 (69.9)
159 (64.6) 144 (58.5) 159 (64.6)
486 (55.6) 418 (47.8) 453 (51.8)
Psychosocial Being dissatisfied with my personal life Feeling anxious or nervous Experiencing poor memory Accomplishing less than I used to Feeling depressed, down or blue Being impatient with other people Feelings of wanting to be alone
122 194 226 152 161 122 157
(34.4) (54.6) (63.7) (42.8) (45.4) (34.4) (44.2)
41 76 74 57 74 57 52
(38.3) (71.0) (69.2) (53.3) (69.2) (53.3) (48.6)
78 101 131 98 95 81 94
(47.0) (60.8) (78.9) (59.0) (57.2) (48.8) (56.6)
121 163 206 148 146 121 125
(49.2) (66.3) (83.7) (60.2) (59.3) (49.2) (50.8)
362 534 637 455 476 381 428
(41.4) (61.1) (72.9) (52.1) (54.5) (43.6) (49.0)
Physical Flatulence or gas pains Aching in muscles and joints Feeling tired or worn out Difficulty sleeping Aches in back of neck or head Decrease in physical strength Decrease in stamina Feeling a lack of energy Drying skin Weight gain Increased facial hair Changes in appearance, texture or tone of skin Feeling bloated Low backache Frequent urination Involuntary urination when laughing/coughing
151 256 262 149 252 196 195 212 124 166 69 89 205 263 141 103
(42.5) (72.1) (73.8) (42.0) (71.0) (55.2) (54.9) (59.7) (34.9) (46.8) (19.4) (25.1) (57.7) (74.1) (39.7) (29.0)
46 87 81 57 88 66 67 76 49 62 32 34 68 82 56 44
(43.0) (81.3) (75.7) (53.3) (82.2) (61.7) (62.6) (71.0) (45.8) (57.9) (29.9) (31.8) (63.6) (76.6) (52.3) (41.1)
92 139 132 102 126 119 109 125 75 104 58 67 112 132 99 92
(55.4) (83.7) (79.5) (61.4) (75.9) (71.7) (65.7) (75.3) (45.2) (62.7) (34.9) (40.4) (67.5) (79.5) (59.6) (55.4)
152 209 217 149 200 192 177 191 130 150 88 97 152 203 140 129
(61.8) (85.0) (88.2) (60.6) (81.3) (78.0) (72.0) (77.6) (52.8) (61.0) (35.8) (39.4) (61.8) (82.5) (56.9) (52.4)
441 691 692 457 666 573 548 604 378 482 247 287 537 680 436 368
(50.5) (79.1) (79.2) (52.3) (76.2) (65.6) (62.7) (69.1) (43.2) (55.1) (28.3) (32.8) (61.4) (77.8) (49.9) (42.1)
Sexual Change in your sexual desire Vaginal dryness during intercourse Avoiding intimacy
(n 322) 73 (22.7) 71 (22.0) 79 (24.5)
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Symptom
expenditure, those at normal weight and those that had given birth three times or more had significantly lower mean scores in all subdomains (p 0.05). The women who had a negative perception of the period of the menopause had significantly higher mean scores in the vasomotor domain compared to women with positive perceptions (p 0.05) (Table 4).
DISCUSSION This study examined the impact of symptom frequency, sociodemographic characteristics and other related factors on the quality of life in the menopausal period. The transition from the period of fertility to the period of decreasing ovarian func-
4
(n 91) 38 (41.8) 35 (38.5) 43 (47.3)
(n 139) 69 (49.6) 64 (46.0) 70 (50.4)
(n 186) 70 (37.6) 66 (35.5) 79 (42.5)
(n 740) 252 (34.1) 238 (32.2) 273 (36.9)
tion is a gradual process. For this reason, it is difficult to ascertain a definite age for menopause inception in any woman. This period usually starts at the age of 40 years, varying from one woman to another. The distribution of menopausal age incidence in population-based studies is expressed in a bell-shaped curve that starts around the age of 40 and ends at approximately age 54; the age of menopause is generally seen to vary between the ages of 45 and 55 years8–11,15,17–23. According to the results of various studies conducted in Turkey, the average age of menopause varies between ages 45 and 501,24–28. In the present study, the mean age of menopause was found to be 46.4 1 2 4.4 years. Studies report that physical symptoms are more frequently experienced when compared to symptoms in other
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Menopausal symptoms and quality of life
Ceylan and Özerdoğan
Table 3 Mean scores on MENQOL questionnaire subdomain according to menopausal periods. Data are given as mean 1 2 standard deviation Quality of life score
Menopausal period
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Premenopause Perimenopause Postmenopause 5 years Postmenopause 5 years p Value
Vasomotor (n 874) 2.28 1 2 1.76 3.58 1 2 2.12 4.19 1 2 2.19 3.92 1 2 2.23 0.000
domains8,18–20,29. Our study also supports this. In our study, the vasomotor symptoms were more frequently seen in women who had been in the postmenopausal period for 5 years. The study of Bairy and colleagues reports that women who have been in menopause for 3.5 years experience vasomotor symptoms more frequently29. Various studies indicate that postmenopausal women of 5 years18, perimenopausal 8 women , peri- and postmenopausal women9,17 experience vasomotor symptoms more frequently. In studies, the rate of ‘hot flushes’ in the premenopausal period is between 16.66% and 31.7%; according to our study, it has a lower rate8–10,17. In our study, the mean menopausal age of the women was 46.4 1 2 4.4 years; the mean age of the women in the premenopausal period was 44.4 1 2 3.5 years. This result may be explained by the fact that the frequency of the ‘hot flushes’ symptom was higher in the women in the premenopausal period due to the mean age of these women being close to the mean age of menopause. Our study, consistent with the other studies on psychosocial symptoms, found that these complaints were more frequently experienced in the perimenopausal period and in postmenopausal women who had been in this period for 5 years8,9,17,18. The symptoms in the sexual domain were more frequently experienced by women who had been in postmenopause for 5 years compared to the women in the other groups. The studies conducted also show that postmenopausal women more frequently experience symptoms in the sexual domain when compared to women in pre- and perimenopause8–10. In a study by Poomalar, women in the postmenopausal period experienced all symptoms more frequently when compared with the pre- and perimenopausal women18. When the entire group is taken into consideration, the most frequently experienced symptoms in our study were ‘feeling tired and worn out’ (79.2%), ‘aching in muscles and joints’ (79.1%) and ‘low backache’ (77.8%). There are studies with results similar to our study findings8,17,18,20,29. There are also studies in which the most frequently experienced symptoms have been reported to be ‘experiencing poor memory’ (84.1%)19 and ‘hot flushes’ (79.6%)1. The least commonly experienced symptom in our study was ‘increased facial hair’ (28.3%). While there are studies reporting findings similar to ours1,17,29, there are other studies that have
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Psychosocial (n 874) 2.61 1 2 1.48 3.05 1 2 1.27 3.23 1 2 1.65 3.56 1 2 1.75 0.000
Physical (n 874)
Sexual (n 738)
2.93 1 2 1.28 3.35 1 2 1.16 3.66 1 2 1.42 3.98 1 2 1.46 0.000
1.88 1 2 1.70 2.66 1 2 1.98 3.22 1 2 2.55 2.90 1 2 2.50 0.000
found ‘being dissatisfied with my personal life’8,20, ‘night sweats’10 and ‘vaginal dryness during intercourse’18 to be the least frequently experienced symptoms. In our study, the highest mean scores were exhibited in the vasomotor and physical domains by women who had been in postmenopause for 5 years and in the psychosocial and physical domains by women who had been in postmenopause for 5 years. While there are studies in the literature that indicate, similar to our study, that postmenopausal women exhibit the highest mean scores on all of the subdomains of the MENQOL questionnaire7,19, there are also studies that report that perimenopausal women exhibit the highest mean scores in the vasomotor, psychosocial and physical domains and that postmenopausal women have the highest mean scores in the sexual domain8,10. Som and Ray have asserted that, as the duration of the menopause increases, the mean scores in the vasomotor domain decrease (p 0.001) while mean scores in the psychosocial, physical and sexual domains increase significantly (p 0.05)11. In our study, the women with the lowest mean scores in all subdomains were in the age group 40–44 years (p 0.001). In a study conducted by Williams and colleagues, the lowest mean scores were found to be in the age group 60–6515. Fallahzadeh’s study reports lowest scores in women aged 60–65 years in the vasomotor domain and in the 45–49-year age group in the psychosocial, physical and sexual domains6. Our study did not evaluate the subdomain of sexuality in the group of unmarried women since sexuality out of marriage is an unwelcome and rare occurrence in Turkish society. It was discovered that widowed or divorced women had the significantly highest mean scores in all subdomains (except for sexuality) (p 0.001). This finding suggests that widowed or divorced women lack the support mechanisms they need as a result of prejudice and social isolation in Turkish society which causes them therefore to experience menopausal symptoms more intensely. Hafız and colleagues found in their study that women with no partners tended to have significantly lower mean scores in the physical and sexual domains compared to women who did have partners (p 0.05)20. In the study of Ghazanfarpour and colleagues, unmarried women, as in our study, had the lowest mean scores in all subdomains (except in the sexual domain)30. The uneducated women in
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Menopausal symptoms and quality of life
Ceylan and Özerdoğan
Table 4 Mean scores on MENQOL questionnaire subdomain according to women’s characteristics. Data are given as mean 1 2 standard deviation Quality of life score
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Characteristics
Vasomotor (n 874)
Psychosocial (n 874)
Physical (n 874)
Sexual (n 738)
Age group (years) 40–44 45–49 50–54 55–59 p Value
2.24 1 2 1.74 3.34 1 2 2.21 3.85 1 2 2.15 4.03 1 2 2.24 0.000
2.62 1 2 1.50 3.05 1 2 1.54 3.15 1 2 1.55 3.60 1 2 1.84 0.000
2.84 1 2 1.28 3.40 1 2 1.32 3.54 1 2 1.27 4.22 1 2 1.53 0.000
1.83 1 2 1.66 2.57 1 2 2.15 2.78 1 2 2.33 3.26 1 2 2.69 0.000
Marital status Unmarried Married Widow/divorced/separated p Value
2.60 1 2 1.92 3.21 1 2 2.20 3.73 1 2 2.10 0.011
2.55 1 2 1.71 2.99 1 2 1.60 3.49 1 2 1.64 0.001
2.66 1 2 1.18 3.39 1 2 1.38 3.70 1 2 1.57 0.014
* 2.49 1 2 2.20 * *
Educational status Illiterate Primary school Middle school High school University/college p Value
4.69 1 2 2.13 3.41 1 2 2.21 2.72 1 2 1.86 2.91 1 2 2.13 2.57 1 2 2.01 0.000
4.12 1 2 1.71 3.20 1 2 1.62 2.74 1 2 1.49 2.44 1 2 1.41 2.65 1 2 1.45 0.000
4.41 1 2 1.43 3.49 1 2 1.37 3.16 1 2 1.49 3.10 1 2 1.31 2.99 1 2 1.31 0.000
3.34 1 2 2.62 2.56 1 2 2.19 2.34 1 2 2.25 2.05 1 2 1.97 2.35 1 2 2.05 0.009
Occupational status Working Not working p Value
3.03 1 2 2.13 3.32 1 2 2.20 0.117
2.76 1 2 1.43 3.12 1 2 1.65 0.023
3.17 1 2 1.38 3.47 1 2 1.42 0.016
2.38 1 2 2.25 2.51 1 2 2.19 0.376
Perception of income Income expenses Income expenses p Value
3.00 1 2 2.08 3.65 1 2 2.28 0.000
2.79 1 2 1.48 3.42 1 2 1.74 0.000
3.18 1 2 1.31 3.76 1 2 1.49 0.000
2.26 1 2 2.00 2.82 1 2 2.43 0.007
Body mass index (kg/m2) 18.5 (underweight) 18.5–24.99 (normal) 25.00–29.99 ( overweight) 30 (obese) p Value
3.19 1 2 2.50 2.88 1 2 2.09 3.29 1 2 2.15 3.57 1 2 2.27 0.004
3.52 1 2 1.59 2.86 1 2 1.65 3.02 1 2 1.54 3.22 1 2 1.69 0.033
3.32 1 2 0.82 3.12 1 2 1.43 3.39 1 2 1.41 3.71 1 2 1.38 0.000
3.62 1 2 2.51 2.21 1 2 2.07 2.66 1 2 2.27 2.43 1 2 2.17 0.023
Parity 2 3 p Value
3.46 1 2 2.26 2.97 1 2 2.04 0.002
3.33 1 2 1.63 2.62 1 2 1.50 0.000
3.57 1 2 1.47 3.18 1 2 1.30 0.000
2.76 1 2 2.34 2.10 1 2 1.93 0.000
Perception of menopause Positive Negative p Value
3.01 1 2 2.07 3.43 1 2 2.25 0.007
3.01 1 2 1.59 3.07 1 2 1.64 0.691
3.39 1 2 1.46 3.43 1 2 1.39 0.462
2.36 1 2 2.11 2.57 1 2 2.26 0.220
*, Only married women were assessed
our study exhibited the highest mean scores in all subdomains. There are studies that support this finding1,7,9,17,30. Having an education makes a positive contribution to women’s lives in that they attain a higher level of income and opportunities.
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The higher quality of life of educated women, as opposed to the uneducated, may be explained by the fact that these women are more easily able to reach the knowledge, support and services they need with respect to their health. While in
Climacteric
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Menopausal symptoms and quality of life Fallahzadeh’s study women who were university graduates exhibited the highest mean scores in the vasomotor domain, they revealed the lowest mean scores in the psychosocial, physical and sexual domains6. In our study, the housewives who were classified as the unemployed group were seen to have significantly higher scores in the psychosocial and physical domains (p 0.05). In the study of Som and Ray, working women had higher scores in the vasomotor area while unemployed women had significantly higher scores in the psychosocial, physical and sexual domains (p 0.05)11. In our study, the women whose income was lower than their expenditure had significantly lower mean scores in all subdomains (p 0.05). In Poomalar’s study, it was seen that women with a monthly income of 5000Rs experience all the subdomain symptoms less18. In the study of Fallahzadeh, women with higher levels of income had lower mean scores in the psychosocial and physical areas (p 0.05)6. Our study revealed that obese women had the highest scores in the vasomotor and physical domains whereas underweight women had the highest scores in the psychosocial and sexual domains. Studies indicate that, as BMI increases, all sub domain mean scores on the MENQOL increase and quality of life suffers9,15,20,30.
CONCLUSION When the female population in the climacteric period of life is considered together with the menopausal complaints experienced in this period, it can be said that menopause is an important societal issue. In women living through the climacteric period, the postmenopausal period is the part of the cycle
Ceylan and Özerdoğan that most commonly has an impact on the quality of life. Within the postmenopausal period itself, while vasomotor and sexual domains of life are most adversely affected in the first 5 years, the psychosocial and physical areas are more commonly affected in women who have been in postmenopause for 5 years. Factors such as having a higher level of education, working and having a normal weight have a positive effect on quality of life. For women to have a better quality of life, policies that will address the needs of women in all of their life cycles need to be adopted and sustained with sensitivity so that support can be provided, both socially and in health services.
Limitations This study has a few limitations. First, the study is of crosssectional design. Only relationships have been defined between the domains of quality of life and the independent variables in the study. The examination of causal relationships is weak. There is, therefore, a need for a cohort study with follow-up to be able to show the effects of independent variables on the quality of life. Second, because responses about symptoms in the sexual domain came only from married women, the quality of life of the other women in terms of sexuality could not be explored. Conflict of interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper. Source of funding Nil.
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