Quality of Life after Menopause in Pakistani Women

Background: With the increase in life expectancy of women all over the world, women are expected to spend almost 1/3rd of their life in menopause phase, usually starting in 4th to 5th decade of life. Objective: This study was planned to look for quality of life of women during menopause in Pakistan. Material and methods: This cross-sectional study was conducted at Gynaecology and Obstetrics department of Lady Atchison Hospital, Lahore over a period of 3 months from June, 2015 to August, 2015. Menopause-Specific Quality of Life Questionnaire (MENQOL) was distributed among 120 patients with the age range of 51-80 years presenting in Outdoor department of the institution. All the demographic details and MenQol results were analyzed. Also Odd’s ratio (OR) was calculated for these symptoms according to age groups of the patients. Results: The mean age of the patients was 60 ± 5.8 years. The mean age of patients at time of menarche was calculated as 13.4 ± 1.80 years and the mean age at menopause was 49.10 ± 3.98 years. We found that the most common symptom of the patients in our study was low backache and the least reported symptom was drying skin. The OR was also calculated for various symptoms according to age of the patients but it was found significant only (OR:10.9; (4.467 – 26.58) for vasomotor symptoms in our study. Conclusion: Menopausal symptoms may vary in different parts of the world. Therefore exact determination of these symptoms in our society is essential as it can help us to identify preventable factors and educate our women about their quality of life. Gy ne col ogy & Obetrics ISSN: 2161-0932 Gynecology & Obstetrics


Introduction
Menopause is a normal physiological process in every woman's life [1,2]. It is usually defined as 12 months of amenorrhea after the final menstrual period. This process is the result of complete or partial absence of estrogen release from ovaries as well as depletion of ovarian follicles. Menopausal period is further divided into early menopause and late menopause. Early menopause is the period of first five years after final menstrual cycle; while the period after five years is termed as late menopausal period [3].
Quality of life (Qol) has been defined by World Health Organization (WHO) as "an individual's perception of his/her position in life in the context of the culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards and concerns" [4]. Therefore it is a subjective assessment of every person about his/her well-being [5]. Various studies have documented the fact that after menopause, the Qol of most of the women falls drastically [6]. However at the same time some studies have shown the minimal change in Qol after menopause [7,8].
The Qol among menopausal women is being increasingly discussed in the literature. Specifically, vasomotor and psychological symptoms are the most common and the most bothersome in most of the women. Vasomotor symptoms may be present among as much as 95% of postmenopausal patients which shows the gravity of the situation. However, there is minimal literature available on Qol in Pakistani women after menopause. Nisar et al. had conducted a study and they found that menopause related symptoms had negative effect on the quality of life of postmenopausal women in Pakistan [9]. In general Qol of women in third world countries is considered as lower than rest of the world but literature is scarce over the topic. As due to longer expected lives, now women are spending about 20-30 years of their lives in this period. So there is a need to address Qol, particularly in our population where women are less aware regarding menopausal symptoms and they have misconceptions about these symptoms. Therefore, we conducted this study to find the Qol in Pakistani women.

Material and Methods
After approval from hospital ethical review board, this study was planned. It was a cross-sectional study, conducted at Gynecology and Obstetrics department, Lady Atchison hospital, Lahore over a period of 3 months from June, 2015 to August, 2015. All the female patients with the age range of 51-80 years, having developed menopause were included in the study. Those patients taking hormonal treatment during post-menstrual period and those with mental and physical problems or systemic diseases were excluded from the study as they can interfere our results and patients can misinterpret the menopausal symptoms. Written informed consent for inclusion in the study was obtained from all patients. Menopause was defined as 12 months of amenorrhea after the final menstrual period. All the patients were supposed to fill a questionnaire proforma designed for the study. All the demographic details of the patients including age, age at menarche and menopause, educational status and marital status were noted. The quality of life of the patients was assessed by Menopause-Specific Quality of Life Questionnaire (MENQOL). The MENQOL is a selfadministered proforma and consists of a total of 29 items in a Likertscale format. Each item assesses the impact of one of four domains of In our study, we found that low backache and other physical symptoms were most prevalent in our patients. In a similar study by Nusrat et al., most common symptoms among menopausal women were found to be backache and bodyaches in Pakistani women [15], these symptoms are more severe in women who don't do exercise. Similarly in another study by Nisar et al., most common symptom was bodyaches in 81.7% of patients [9]. In an Indian study, most commonly found symptom was fatigue in 61% of patients [14]. This is in contrast to most of the western studies, in which vasomotor symptoms particularly hot flushes is found as more common [13,16]. This may be due to cultural differences among different regions. In a study conducted by Zeleke et al. factors which were significantly associated with post-menopausal symptoms included age, bilateral oophorectomy, obesity and being a caregiver for another person [17]. menopausal symptoms, as experienced over the last month: vasomotor (items 1-3), psychosocial (items 4-10), physical (items 11-26), and sexual (items 27-29). Items pertaining to a specific symptom are rated as present or not present, and if present, how bothersome on a zero (not bothersome) to six (extremely bothersome) scale [10]. All the data were noted on the proforma. A sample size of 115 female patients was calculated using 95% confidence level and 4% margin of error taking the expected vasomotor symptoms in 95% of post-menopausal women [11]. All the data were analyzed using SPSS version 20. For quantitative variables like age of patients and score of quality of life tool mean ± S.D were calculated. For qualitative variables frequency and percentages were calculated. The MenQol score for each question was stratified according to the age groups of the patients and Odd's ratio (OR) was calculated.

Results
A total of 115 patients were included in the study. The mean age of the patients was 60 ± 5.8 years. All the demographic details of the patients included in the study are summarized in Table 1. The mean age of patients at time of menarche was 13.4 ± 1.80 years. The mean age at menopause was found to be 49.10 ± 3.98 years. The mean gravidity of patients in the study was 4.81 ± 2.03 and parity was 3.88 ± 1.66. The mean duration after marriage was calculated as 38.2 ± 30.62 years. The MenQol score of the patients is summarized in Table 2. We found that the most common symptom of the patients in our study was low backache in 98 of 115 patients (85.2%) and vaginal dryness in 97 of 115 patients (84.3%). The least reported symptom by the patients was drying skin, reported by 33 patients (28.6%) and facial hair by 38 patients (33%). Also stratification of each symptom group according to age groups was done. Odd's ratio (OR) was calculated for each group and is summarized in Table 3. OR was found significant for vasomotor symptoms in different age groups (OR:10.9; 95% CI (4.467 -26.58)).

Discussion
As the life expectancy has increased all over the world, therefore it is presumed that women are now expected to spend almost 1/3rd of their life in menopausal phase [12]. Therefore Qol of women after menopause, particularly in our setup, is needed to be assessed. Among post-menopausal women, most commonly encountered symptoms are that of vasomotor including hot flushes and night sweats which women face in early menopause phase.. According to a study, 88% of women in United States suffer from hot flushes in menopausal age [13]. Mahajan et al., found that 44% of the women are affected in negative manner during menopause stage. Therefore this study was conducted to look into prevalence of symptoms in post-menopausal women in our setup [14] so that awareness regarding its symptoms and their management should be discussed with women in premenopausal period. This education regarding her health will give benefit later in life.   There are multiple tools available for assessment of Qol among menopausal women which include both general and specific questionnaires. One of the most commonly validated scales for Qol in menopausal women is MENQOL. The other commonly used scales include 36-item short-form (SF-36), World Health Organization Quality of Life (WHOQOL-BREF), Utain Quality of Life Scale (UQOL), Woman's Health Questionnaire (WHQ) and Greene Climacteric Scale. However in a systematic review by Jenabi et al., MenQol was found to be most validated and most commonly used scale in literature and this is the same scale we have used in our study [10].

Number of Patients
Menopause hormonal therapy (MHT) is usually considered as the best therapy for menopausal symptoms. It is thought to be reducing vasomotor symptoms and hot flushes and improves sleep problems among menopausal symptoms [18]. However there are multiple contradictory studies also available in the literature regarding use of MHT [19]. About duration of use of these drugs is not clear because of risk of cancers associations with this therapy. There are multiple treatment options other than MHT proposed by different authors for menopausal symptoms. Fu et al. conducted a randomized trial on usage of Chinese herbal medicine among patients with menopause and they found significant improvement in vasomotor symptoms after 8 weeks of usage of herbal granules [20]. In another study by Nourozi et al., Soy milk ingestion was compared with low fat cow milk. In this study it was found that significant improvement in post-menopausal women occurred in vasomotor, psychosocial and physical domains with the usage of soy milk [21]. Physical activity has also been found having positive impact on Qol among post-menopausal women. Moilanen et al. conducted an 8-years follow up study among finish women and found that women who increase or maintain their physical activity, they had greater chances of increased score in Qol scales.

Limitations
Our trial had limitations including limited sample size and it was not multi-centric. Also we did nit calculated the risk factors which may lead to menopausal symptoms.

Conclusion
Thus we conclude that in our setup, a large number of women suffer from post-menopausal symptoms. Therefore we recommend heavy campaigns on larger scales for education of women regarding these problems so that they can be educated in a better way. Also more trials are needed to be conducted to look into specific causes of the symptoms among women in our country.