Abstract
Objective
To assess menopausal symptoms and determine awareness of menopausal related information in mid-aged women.
Methods
This was a cross-sectional study in which 140 women aged 40 to 60 years from Guayaquil, Ecuador were surveyed with the short 10-item Cervantes Scale (CS-10) and a questionnaire containing personal data and questions assessing awareness of menopause related information.
Results
The mean age of the sample was 48.0 ± 5.6 years. More than half of surveyed women had low education and non-urban residency, none were on menopausal hormone therapy, 33.6% had hypertension, 35% were postmenopausal, 78.6% had an increased body mass index (overweight/obese) and 92.9% had abdominal obesity (waist > 88 cm). The average CS-10 score was 15.3 ± 9.0 with a median of 14.0. The three most frequent menopausal symptoms were muscle-joint pain (75.0%), changes in skin texture (74.3%) and vaginal dryness (71.4%). Regarding awareness of information related to the menopause, it was found that 98.6% of women had no idea about what the menopause is and the average age of its onset. Interestingly, although 61.4% knew that during the menopause there is weight gain, 57.9% were sedentary. Married, postmenopausal, older and less educated women presented higher mean total CS-10 scores. Contrarily, those with less awareness of menopause related information present lower scores.
Conclusion
In this low-income mid-aged female sample there was a high rate of non-awareness regarding information related to the menopause, including an unhealthy cardiometabolic profile. There is a need for educational programs aimed to increase awareness in this high-risk population in relation to the surveyed aspects in order to improve their health status and prevent chronic conditions.
Introduction
Worldwide, menopause, the last menstrual period, is a determining experience in women’s lives, and the perception of this event may vary depending on the studied population [Citation1]. Despite the fact that there are studies that indicate that the perception of health is worse in menopausal women [Citation2], there is little interest in this topic among women [Citation3]. Reports indicate that the perception of the menopause changes as women age [Citation4], even more if she is over 45 years of age. Studies have also observed that there are differences in the perception of menopause and quality of life between couples [Citation5], and between cultures [Citation1], this being affected by psychosocial factors such as stress that correlate with more severe menopausal symptoms [Citation6].
In Ecuador, there are no specific public or private health programs intended to manage women during the menopausal transition or after menopause, and despite being a physiological stage, some women experience discomfort that severely compromises their quality of life [Citation7, Citation8]. A useful tool to identify the presence and severity of symptoms related to the menopause is the short 10-item Cervantes Scale (CS-10) [Citation9], which has reported good sensitivity and reliability [Citation10]. Furthermore, this scale has good psychometric properties to measure or correlate factors that alter women’s quality of life [Citation11,Citation12].
During the menopausal transition, due to the progressive decrease of ovarian estrogens, women present a variety of symptoms that deteriorate their quality of life. Despite this, it is thought that the majority of women are unaware of the manifestations related to the climacteric stage [Citation13–15]. In one study, 770 middle-aged Spanish women [Citation16] were evaluated with 56 questions regarding the climacteric, finding scarce knowledge about this stage among them. As health providers, it is important to identify symptoms, in order to provide timely treatment and thus, avoid the negative impact that symptoms have on women’s quality of life [Citation17]. Measuring the severity of symptoms presented by middle-aged women, and, in addition, determining their knowledge about menopause and related topics, will help develop future programs intended to educate them on the identification of relevant clinical signs of deterioration of quality of life linked to the menopause. There are studies that support the theory that educating middle-aged women on changing their lifestyle may aid at preventing chronic diseases [Citation18,Citation19]. The aim of the present research was to assess menopausal symptoms and determine awareness of menopausal related information in mid-aged women.
Methods
Study design and participants
This was a non-experimental cross-sectional study that aimed to evaluate menopausal symptoms and awareness of menopause related information in 140 women aged 40 to 60 years who were attending routine annual gynecological checkups from November 2021 to May 2022 at the Outpatient Clinic of the University General Hospital of Guayaquil, Guayaquil, Ecuador. This facility of the Ministry of Health, managed by the University of Guayaquil, provides healthcare to the low socio-economic population of individuals that live in peripheral areas of Guayaquil, Ecuador. The study was approved by the Department of Academics and Research of the mentioned Hospital through authorization No. 051-2019-DI-HUG. All participants were informed about the study, its objectives, instruments to be used and, after obtaining informed consent they were surveyed.
Study instruments
General data
Bearing in mind the objectives of the study, we prepared a data collection sheet that contained: 1) socio-demographic (age, parity, education, marital status, residency, age at menarche, menopausal status, lifestyle and habits [sedentary and smoker]) and personal medical history information (hypertension, diabetes, history of hysterectomy); and 2) ten questions on knowledge regarding different aspects related to the menopause, and two questions on education related to the menopause. If the participant responded incorrectly or reported not knowing, the response was recorded as “don’t know = 0”. If answered correct 1 point was assigned to that question.
Menopausal status (pre-, peri- and postmenopausal) was defined according to STRAW +10 criteria [Citation20]. We recorded for each woman weight (k) and height (m), in order to determine body mass index (BMI), calculated as weight (k)/height (m)2. According to calculated BMI, women then classified as being overweight (BMI: 25–29.99 k/m2) or obese (BMI: ≥ 30 k/m2). The latter category was sub-classified as obesity grade 1 (BMI 30–34.99 k/m), obesity grade 2 (BMI 35–39.99 k/m2) or obesity grade 3 (BMI ≥ 40.0 k/m2) [Citation21]. Other recorded anthropometric measures included: neck, abdominal hip circumferences (cm) and waist/hip ratio. Abdominal obesity was defined as a waist circumference of > 88 cm [Citation22] and a waist/hip ratio of >.84 as cardiometabolic risk [Citation23].
The cervantes short 10 item Scale (CS-10)
The CS-10 was used to evaluate the prevalence and the severity of menopausal symptoms. The tool assesses 10 symptoms which are rated in a Likert fashion as zero (not present); one (mild), two (moderate), three (severe) or four (very severe). The scores obtained for each of the 10 items are then summed up to yield a total CS-10 score, which can range from 0 to 40, with higher scores indicating more severe menopausal symptom, and thus impaired quality of life. The CS-10 is a short version of the original 29-item scale which was developed from a large cohort of Colombian mid-aged women [Citation17], and further applied and validated among Ecuadorian [Citation9] and Portuguese women [Citation10].
At the end of the survey, a 10-min educational talk was given per participant, explaining the conceptual errors they had regarding the menopausal transition/menopause, in order to clarify doubts and strengthen their level of knowledge of these aspects.
Sample size
Sample size calculation was performed with the EPI-INFO 7.2 statistical program. A minimal sample size of 134 women was determined, considering that the center covers an approximate female population of 5,000 between 40 and 60 years, and assuming that 50% of surveyed women would present increased Smirnov menopausal symptoms with a 7% desired precision and a 90% confidence level.
Statistical analysis
Statistical analysis was performed with the EPI-INFO program version 7.2 for Windows (CDC, Atlanta, Georgia, USA). Data are presented as means, standard deviations, medians, or frequencies (%). The Kolmogorov–test was used to determine the normality of data distribution and according to this for comparisons we used the Student’s T test (normal continuous data) or the Mann–Whitney U test (non-normal continuous data). Binary logistic regression analysis was performed to analyze factors associated to higher CS-10 scores. Logistic regression model was created from variables achieving significance upon bivariate analysis. For all calculations, a p value of <.05 was considered as statistically significant.
Results
During the study period, 140 women aged 40 to 60 were surveyed. Mean age was 48.0 ± 5.6 years, with more than 50% of women having an age between 45 and 54 years. A 44.3% of participants had low education (defined as <12 years of study or only with primary schooling), 47.1% were married, 80% were multiparous (mean parity of 4.3 ± 2.3) and 64.3% had non-urban residency (characterized by scarce basic services, drinking water and electricity) (). Average age of menarche was 12.9 ± 1.6 years and 5.7% had a history of hysterectomy before the age of 50. According to STRAW criteria, most women were perimenopausal (36.4%). A 57.9% were considered sedentary (physical activity of less than 30 min a day), 33.6% had high blood pressure, 11.4% diabetes and 2.9% were active tobacco smokers.
Table 1. Sociodemographic and personal medical information of surveyed women.
The anthropometry of surveyed women is presented in . A 78.6% of the participants were overweight or obese (34.3% and 44.3%, respectively). A quarter of obese participants were grade 1. A 92.9% of women had abdominal obesity defined as increased abdominal circumference >88 cm). Mean waist/hip ratio was 0.95 ± .7, with 95.7% having values above .84.
Table 2. Anthropometry of surveyed women.
Results of the ten questions assessing women’s knowledge regarding different aspects related to the menopause are presented in . Questions 1 and 2 were related to concepts of the menopause, question 3–7 were related to menopausal symptoms and conditions related to the menopause, and question 8–10 were about therapeutic measures. The participants who answered all the questions correctly obtained a total score of 10 (1 point per question). Mean total score achieved by the participants was low, 2.36 ± 1.5 [median 3.0], which means that participating women have little knowledge about aspects related to the menopause. However, a good percentage correctly answered that during this stage there can be depression (70.7%), weight gain (61.4%) and osteoporosis (48.6%).
Table 3. Questions to evaluate knowledge of women on different aspects related to the menopause.
In addition to the 10-item questionnaire, during the 10-min educational personalized talk, 2 more questions were asked, one whether there are programs devoted to the menopause where they receive healthcare, and the other asking whether they learned new concepts after participating in the study. It was observed that 97.9% indicated that they did not know if there were specific menopause care programs in the place where they receive healthcare. Favorably, all participants indicated learning new concepts and clearly understood the topics related to the menopause after the 10-min educational talk.
The presence of symptoms related to the menopause as evaluated with the CS-10 are shown in . The mean total CS-10 score was 15.3 ± 9.0, with a median of 14.0. The three most frequently reported symptoms were muscle-joint pain (75.0%), changes in skin texture (74.3%) and vaginal dryness (71.4%).
Table 4. Presence of menopausal symptoms according to the short 10-item version of the Cervantes Scale (n = 140).
Correlation between total CS-10 scores and female information is presented in (bivariate analysis. It was observed that married, older, postmenopausal and less educated women displayed higher CS-10 scores. Interestingly, women with less knowledge regarding aspects related to the menopause (< 4 total points in the 10-item survey) displayed less severity of menopausal symptoms (lower total CS-10 scores). The significant correlations found upon bivariate analysis were confirmed by logistic regression analysis.
Table 5. Total CS-10 scores according to characteristics of surveyed womenTable Footnote*.
Discussion
Health care in many countries still faces obstacles that may affect the life of a given patient. The relation between social economic status and mortality is well known, with lower income countries facing increased mortality rates [Citation24] and significant unfavorable effects on cardiovascular health [Citation25]. In Ecuador, 10.8% of the population live in extreme poverty [Citation26] being more frequent in non-urban areas compared to urban ones. This survey was conducted in low-income women who are less educated, mostly live in non-urban areas with scarce basic services and have an unfavorable cardiometabolic profile (sedentary and increased BMI); hence, having a higher risk of cardiovascular disease (CVD) and mortality risk (overall and related to CVD). Independent of socio-economic status, the correlation between less physical activity/increased BMI and higher mortality rates (overall and related to CVD) has been seen in women from the US, Europe and Asia [Citation27–30]. Although we did not aim at evaluating CVD risk in the women of our study, the high proportion (78.6%) of women found to have increased BMI (≥ 25 k/m2) certainly increases this risk. In one study from Cuba, a country with a similar low-income profile, more than 50% of adult participants (men and women) had increased BMI values which correlated with hypertension [Citation31]. In a previous study, performed in 3,965 postmenopausal women from Latin America, abdominal obesity (defined as waist > 88 cm) was better and optimal to define the metabolic syndrome compared to obesity determined by BMI values [Citation32]. Indeed, after menopause there is a higher deposit of adiposity in the abdominal area than in the rest of body, hence, BMI values do not necessarily correlate with waist perimeter values. This was observed in the present study in which an alarming 92.9% presented abdominal obesity, which is more than two-fold compared to the 44.3% presenting obesity defined by BMI values. In parallel, 95.7% of women presented a waist/hip ratio > 0.84 considered the cutoff value defining abnormality. These higher rates (abdominal obesity and high waist/hip ratio) together with a 57.9% of women being sedentary are major concerns in terms of CVD risk.
Another important aspect to consider in our study is education. Lower education has been correlated to higher mortality [Citation33]. There is a higher relative risk for all-cause mortality, and cardiovascular and cancer related mortality in populations with low education [Citation34]; thus, adults with higher education live healthier and have a longer lifespan [Citation35]. In our studied population, 44.3% had low education and these women demonstrated deficiencies in answering questions that assessed knowledge regarding aspects related to the menopause. Only 2 out of 140 participants displayed correct conceptual knowledge about the menopause. Our results correlate with those of a study performed by Ayora Apolo et al. [Citation36] in 506 women from the City of Loja in Andes highlands of Ecuador. in terms of low knowledge when it comes to defining the menopause and its stages. Intensity of menopausal symptoms may also be affected by low education. Indeed, women of our study with lower education presented higher CS-10 scores, thus more severe symptoms. Interestingly, and contrary to this, women with less knowledge regarding the menopause (< 4 total points in the 10-item survey) displayed less severity of menopausal symptoms (lower total CS-10 scores). The possible answer to this dichotomous situation is that these women with less knowledge cannot correctly identify menopausal related symptoms. A similar finding has been reported in another study carried out by Requena Vera et al. [Citation37] in women of similar age living in Guayaquil, but surveyed at a different health care institution that also attends low-income individuals. Syed Alwi et al. [Citation38] have reported that women with higher educational level and those premenopausal express more positive opinions regarding the menopause.
The Ministry of Public Health of Ecuador has healthcare guidelines that are mostly outdated, and none address the climacteric stage nor the menopause. Moreover, educational programs in public healthcare units that address issues related to the menopause are practically non-existent. This is of concern when we compare ourselves to the US or Europe. Only 2.1% of our participants indicated to have received an educational talk about the menopause in their healthcare unit. This same trend has been found in another Ecuadorian study, carried out by Altamirano Cárdenas et al. [Citation39] in a unit of the Morona Santiago province in the Amazon, and a study carried out in Mexico by Pelcastre et al. [Citation40].
Finally, regarding the presence of menopausal symptoms, and factors correlating with the intensity, our study found that the three most frequently reported symptoms were muscle-joint pain, changes in skin texture and vaginal dryness, and the intensity of symptoms (higher CS-10 scores) correlated to female age, educational level, marital status and postmenopausal stage. These findings agree with those of a previous multicenter study carried out in 8373 mid-aged Latin American women, that found muscle-joint pain as the most frequent menopausal symptoms [Citation41]; and found similar factors associated to the severity of menopausal symptoms [Citation42]. We hypothesize that the higher prevalence of muscle joint pain is related to excessive body weight. There is a need for further studies analyzing this association but in a larger population. Contrary to our findings, studies from developed countries have reported vasomotor symptoms as the most frequent and bothersome menopausal symptom, mainly seen in African-American and Hispanic women [Citation43,Citation44].
Regarding the limitations of our study, we must mention its cross-sectional nature that does not allow determining causality; and the small sample size that does not allow generalizing of our results to the whole Ecuadorian population. However, as a strength one can mention the unique characteristics of the surveyed population, that is low-income. Indeed, as already mentioned the University Hospital (healthcare facility of the Ministry of Public Health) attends basically the low-income population of Guayaquil.
In conclusion, in this low-income mid-aged female sample there was a high rate of non-awareness regarding information related to the menopause, including an unhealthy cardiometabolic profile. Finding that even if participants knew that at menopause women gain weight, more than half were sedentary. Most of our participants are obese, have low education and low income, aspects that increase cardio-metabolic risk which significantly increases future related mortality.
In the field of menopausal healthcare, patient education is a fundamental aspect for the accurate identification of symptoms and the timely initiation of treatment. Interventions aimed at changing lifestyles and enhancing education in mid-aged women has beneficial effects on various systems (i.e. bone, cardiovascular) [Citation45,Citation46]. As for our country, we suggest that the national menopause society urgently elaborate guidelines for the management of the menopause, in addition to promote educational programs aimed at increasing awareness in high-risk populations of the various aspects explored in the present survey in order to improve female mid-aged health status and prevent chronic conditions.
Authors’ contributors
D. Salazar-Pousada and P. Chedraui were involved in study conception and design. V. Ortega-Uscocovich carried out the surveys. P. Chedraui and C. Ramírez-Morán performed the statistical analysis. D. Salazar-Pousada and P. Chedraui performed drafting of the manuscript. All authors were involved in critically revising the manuscript for its intellectual content, and the final approval of the manuscript was performed by all authors.
Acknowledgment
The authors thank the participants and the authorities of the University General Hospital of Guayaquil (Guayaquil-Ecuador) for collaborating in the development of this study.
Disclosure statement
The authors declare having no conflicts of interest. The preliminary data of this study were presented by P. Chedraui as a poster at the 20th World Congress of Gynecological Endocrinology, May 11–14 2022, Florence, Italy.
Data availability statement
All required information regarding the study protocol and collected data will be made available upon request to researchers who provide a methodologically sound proposal. Only the analysis required to achieve the aims in the approved proposal will be permitted. Proposals should be directed to [email protected] Data requestors must sign a data access agreement form to gain access.
Additional information
Funding
References
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