Menopause Related Symptoms and Their Correlates: A Community Based Cross Sectional Study in Kollam District, Kerala

MENOPAUSE RELATED SYMPTOMS AND THEIR CORRELATES:
A COMMUNITY BASED CROSS SECTIONAL STUDY

IN KOLLAM DISTRICT, KERALA
SAJITHA.S
Dissertation submitted in partial fulfilment of the
requirements for the award of
Master of Public Health
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY, TRIVANDRUM
THIRUVANANTHAPURAM, KERALA, INDIA-695011
OCTOBER 2017
TABLE OF CONTENTS
CONTENTS
List of Figures vii
List of Tables viii
List of Abbreviations ix
Abstract x
Chapter Page
No.
Chapter 1 Introduction 1-5

1.1 Background 1
1.2 Rationale of the study 3
1.3 Research Questions 4
1.4 Objectives of the study 5
1.5 Chapterization plan 5
Chapter 2 Review of Literature 6-21
2.1 Introduction 6
2.2 Literature review strategy 6
2.3 Menopause related symptoms and determinants-Global scenario 7
2.4 Menopause related symptoms and determinants- Indian scenario 10
2.5 Menopause and long term health issues 13
2.6 Metabolic syndrome and menopause 16
2.7 Menopause and quality of life 18
2.8 Health seeking behaviour and menopause 19
2.9 The concept of healthy menopause 20
Chapter 3 Methodology 22-40
3.1 Study Design 22
3.2 Study settings 22
3.3 Study population 23
3.4 Sample size estimation 23
3.5 Sample selection procedure 23
3.6 Subject selection procedure 27
3.7 Inclusion and exclusion criteria 28
3.8 Ascertainment of menopausal status 29
3.9 Definition of menopausal stages 31
3.10 Data collection procedure 32
3.10.1 Research tool 33
3.10.2 Data collection on the field 38
3.11 Ethical consideration 38
3.10.4 Data entry and analysis 39
3.10.5 Data storage, transfer and management 39
3.11 Plan for dissemination 39
3.12 Expected outcome 40
Chapter 4 Results 41-61
4.1 Introduction 41
4.2 Participant profile 42
4.2.1 Profile of the participant by socio-economic characteristics 42
4.2.2 Profile of participants by health related characteristics 44
4.2.3 Pattern of health seeking for gynecological morbidities and other 46
i
chronic conditions
4.2.4 Profile of participants by age and nature of menopause 47
4.3 Experience of menopause related symptoms(MRS) 49
4.4 Patterns of health care seeking MRS 52
4.4.1 Health care seeking and preferences of health systems for care 52
4.4.2 Place for Health care seeking for MRS 53
4.4.3 Frequency of care seeking and satisfaction with treatment forMRS. 54
4.5 Correlates of MRS 54
4.5.1 Menopause related symptoms (MRS) and associated factors 56
4.5.2 Menopause related symptoms and other factors 57
4.6 Health care seeking for MRS and associated factors 60
4.6.1 Health care seeking for MRS and nature of menopause, socio- 60
economic factors
4.6.2 Health care seeking for MRS and lifestyle factors, reproductive health 61
history, other medical conditions
Chapter 5 Discussion 64-75
5.1 Summary of key findings 64
5.2 Menopause related symptoms and its correlates 70
5.3 Correlates f health care seeking pattern for MRS 72
5.4 Limitation of the study 74
5.5 Strengths of the study 74
5.6 Conclusion 75
5.7 Policy Implication 75
REFERENCE
ANNEXURE I –Flow chart of Literature search process
ANNEXURE II-Name and identification number of clusters in the study
ANNEXUREIII-Flow chart of participant recruitment
ANNEXUREIV-Cluster wise report on study participants
ANNEXUREV-Distribution of average age at menopause
ANNEXURE VI-Informed consent(English)
ANNEXUREVII-Interview schedule(English)
ANNEXURE VIII-Informed consent(Malayalam)
ANNEXURE IX-Interview Schedule(Malayalam)
ANNEXURE X-IEC clearance
ii
LIST OF FIGURES
Figure Title Page No.

No.
3.1 Rural and urban participation 24
3.2 Outline for Sample population recruitment. 25
3.3 Description of Chittumala Block-Gramapanchayat wards 25
3.4 Description of KottakkaraBlock-Gramapanchayat wards 26
3.5 Description of Oachira Block –Gramapanchayat wards 26
3.6 Ascertainment of Menopausal Stages in the study 30
3.7 Procedure of waist circumference measurement 35
4.2 Distribution of Menopause related symptoms by GCS scale 50
iii
LIST OF TABLES
Table Title Page No.

No.
3.1 Urban Sample Selection wards list 31
3.2 Green Climacteric scale description 34
4.1 Profile of the participants by socio-economic characteristics, Kollam 43
district, Kerala 2017
4.2 Profile of the participants by health related characteristics, Kollam 45
district, Kerala. 2017.
4.3 Pattern of health care seeking for gynaecological and other chronic health 47
conditions, Kollam district, Kerala, 2017
4.4 Profile of participants by age and nature of menopause, Kollam district, 48
Kerala, 2017
4.5 Prevalence of MRS by domains of the green climacteric scale, Kollam, 49
Kerala, 2017
4.6 Severity of MRS by menopause status and domains of the green 51
climacteric scale, Kollam, Kerala, 2017.
4.7 MRS-Average scores using Green Climacteric Scale, Kollam, Kerala, 52
2017.
4.8 Patterns of health care seeking and preference for type of care for MRS 52
among women with symptoms, Kollam, Kerala, 2017
4.9 Place for health care seeking for MRS, Kollam, Kerala, 2017 53
4.10 Self-reported satisfaction to the treatment and among those who sought 54
treatment for MRS
4.11 Distribution of women by MRS and associated factors like nature of 55
menopause, socio-economic characteristics and socio-economic support,
Kollam, Kerala, 2017
4.12 Distribution of women with MRS and lifestyle factors, reproductive 58
health history, other medical history, Kollam, Kerala, 2017
4.13 Health care seeking for MRS by nature of menopause, type of menopause 60
and socio-economic characteristics, Kollam, Kerala,2017
4.14 Health care seeking for MRS by lifestyle factors, reproductive health 63
history, other medical conditions, Kollam, Kerala, 2017
4.15 MRS Severity and predictors 63
5.1 Mean age at menopause in different studies in India 68
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LIST OF ABBREVIATIONS
AYUSH Ayurveda, Yoga and naturopathy, Unani,

Siddha and Homeopathy
CVD Cardio Vascular Diseases
DM Diabetes Mellitus
FMP Final Menstrual Period
GCS Green Climacteric Scale
HDL High-Density Lipoprotein
MRS Menopause related symptoms
NFHS National Family Health Survey
NSSO National Sample Survey Office
SD Standard deviation
STEPS Stepwise approach to Surveillance
STRAW Stages of Reproductive Aging Workshop
VMS Vasomotor symptoms
WC Waist circumference
WHO World Health Organization
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ABSTRACT
Introduction: Menopause is a biological event characterized by complexity of

factors. On an average one third of the women’s life consists of the post
menopause years, and health care programmes for women do not address concerns
beyond reproductive ages. This study aims to describe the magnitude of
menopause related symptoms, pattern of health care seeking and associated factors.
Method: This is a community based cross sectional study in Kollam district using a
multi stage stratified random sampling strategy. Structured interview schedule with
Green Climacteric scale was used for data collection and analysis was done using
IBM SPSS version.21.
Results: A total of 420 participants were included in the study. The proportion of
women who had at least one menopause related symptom was 95.95(95%CI 93.73-
97.54) and 58.3% women had severe symptoms. Severities of symptoms in
psychological, physical, vasomotor and sexual domains were 56.7%, 70.5%, 49.3%
and 10.2% respectively. Premature menopause (p<0.016), induced nature of
menopause (p<0.031), low economic status (p<0.023), no family support
(p<0.007), history of diagnosis of gynecological morbidity (p<0.002), dislipidemia
(p<0.006) and other medical condition (p< 0.003) were associated with severity of
menopausal related symptoms. About half of them sought health care at least once.
Gynecological morbidity (p<0.006), presence of self-reported DM (p<0.027),
presence of other medical conditions (p<0.025) were associated with seeking
health care.
Conclusions: A high proportion of women are affected by menopause related
symptoms. Care seeking for all symptoms is not uniform, indicative of a lack of
knowledge about the treatable nature of many of these symptoms. Sensitisation of
both women and the health care system may serve to address this issue of
menopause related symptoms and the possibility of treatment for these.
vi
CHAPTER 1
INTRODUCTION
1.1 Background
Demographic transition is a recent phenomenon in developing countries
characterized by decline in fertility, mortality and increase in life expectancy. The
impact of demographic transition on women‘s status is important in terms of
health, economy and gender. The life cycle factors like reduced family size,
changes in marital status, increased dependency ratio, changes in disease pattern,
and aging can affect women varyingly (Kirsty McNay, 2003). The gender specific
health needs of women are different and it is neglected in developing countries
regardless of gender equality and empowering women status goals which were set
by Cairo Declaration of Population and Development.(ICPD, 1994) and United
Nations Sustainable Developmental Goals(United Nations, 2015).
Menopause is considered to be a marker of biological ageing in women(WHO
technical Group, 1996). Menopause is one of the most significant stages in female
reproductive life cycle where there is a transition from reproductive to non
reproductive stage. This brings in a number of physiological changes that affect
the life of a woman permanently. It sets the stage for ageing and accelerates the
process of non-communicable disorders. Historically the association of menopause
and its symptoms was noted by John Leake in 1777(Leake, 1777) .
Natural menopause is indicated by the permanent cessation of menstruation due to
lack of ovarian follicular activity. However, this can be clearly identified only after
one continuous year of amenorrhea. It is difficult to find a biological marker for
1
menopause as it occurring and it can be only identified subsequently.(Utian,
1999a). The complexity of various factors such as hormonal, psychological, social,
cultural and aging factors produces a difference in symptoms and long-term health
outcomes (Utian, 1997).
The symptoms of menopause that appear before, during and after the onset of
menopause vary. India has a large population with 71 million people over 60 years
of age and the menopausal women number about 43 million. The estimated
projected population of India in 2026 will be 1.4 billion, and among those, people
over 60 years will number 173 million(Registrar General of India, 2006). The
number of women in the postmenopausal ages 50–59 years is projected to increase
from 36 million in 2000 to 63 million in 2020.(Khandelwal, 2013).
Slightly over one tenth of the women (11.2%) in the age group 30-39 attained
menopause in India among 30-49 years age group (NFHS-3, 2007) .Given that this
number is not insignificant and runs to millions of women, it is important to have
a national policy with individualized approach in addressing the menopause
related symptoms which is sensitive to the clear event in the women‘s life cycle.
Such a policy would help to reduce the social and economic burden of the
symptoms for elderly women and ensure a quality of life or ensure a healthy life
expectancy. The quality of the menopause experience of women is determined by
their reproductive histories, the environmental conditions under which they have
lived, the conditions under they work, ,the role in the family, the adequacy of their
diet, the diseases to which they are vulnerable either by reason of genetics or
lifestyles, the socioeconomic circumstances , and their access to adequate health
care (Kaufert, 1996).
2
1.1 Rationale for the study
The hormonal and behavioural changes that occur during the menopausal period
lead to a high demand for special health care. Menopause introduces a major
change in the morbidity pattern in middle life of woman. The proportion of
women who experience pre mature menopause either due to biological or
otherwise induced reasons have long duration of exposure to menopause leading
to severe symptoms, when compared to women who have undergone menopause
naturally. The Reproductive, Maternal, Newborn, Child, and Adolescent Health
(RMNCH+A) programme strategy which is based on ‗Continuum of care‘
concept, propagated high impact interventions in the life cycle care for women
does not address the late reproductive age group of women(MOH&FW, 2013).
The health of the women in the later reproductive age and menopause are ignored
by all existing health care programmes.
Menopause does not cause any life threatening conditions, but it affects the
quality of life of the women in the middle ages. In Kerala the life expectancy of
females at birth is 76.3 years (Health information Cell, Kerala, 2013) and average
age at menopause was estimated to be 47.95 years(Subrahmanyam and Padmaja,
2016) or 48.2(Borker et al., 2013) years. Given the expectation of life at birth of
woman in Kerala, approximately 28 years of will be spend in the post menopause
period, with short term and long term menopause related morbidity. Menopause is
physiological event, but its psychological, physical consequences will prevail
throughout these 28 odd years for the woman.
3
The health care needs of the women vary among different stages of life; in her
third phase of reproductive life, it depends on the physiological characteristics and
socio cultural contextual factors. Usually women in this peri-menopause are
negligent about their health and end up with chronic diseases which call for
urgency in public health focus on emerging health issues of middle aged
women(Govil, 2010).
This brings the importance of understanding of health in menopausal women, and
developing appropriate health promotion activities. A supportive, understanding
attitude from any health care system may lead to improved wellness of women in
middle ages(TAKEDA, 2010). Therefore looking beyond the physiology to
understanding of sociodemographic context of individual women by studying
menopause and its correlates gains significance. This can contribute to reducing
the gap between an identified need and care provided and promoting health of the
women.
1.3. Research Questions
I. What is the extent of self reported menopause related symptoms among
35-60 years old women in Kollam district?
II. What are the factors associated (reproductive, sociodemographic, life
style) with menopause related symptoms and health seeking behaviour
among 35-60 years old women?
4
1.4. Objectives of the study
1.4.2. Major objective
To determine the prevalence of self reported menopause related symptoms among
women aged 35-60 years in menopausal transition phase and post menopause
phase.
1.4.3 Minor objectives
To explore the association between socio-demographic, reproductive, lifestyle
factors and menopause symptoms and to identify the pattern of health seeking
behaviour and to find out factors associated with health seeking behaviour.
1.5. Chapterization Plan for the study
The introduction chapter gives a brief summary of the current study topic,
relevance, rationale, research question and objectives of the study in present
context. Chapter two is about the summary of literature related to the topic.
Chapter three describes the methods and materials used for the study, data
analysis, variables, definitions, ethical consideration. Chapter four is the detailed
description of results. Chapter five includes the discussion related to key findings
of the study, strengths and limitation of the study and emerging conclusion, policy
implication and recommendation.
5
CHAPTER 2
REVIEW OF LITERATURE
2.1 Introduction
The review of literature chapter is a summary of accessed literature
regarding menopause related symptoms and the various factors associated
with it in tune with the research questions. The purpose of the literature
review was to find out what is known already with respect to menopause, its
associated factors globally and identify the possible correlates of menopause
related symptoms locally, especially in a Kerala context.
2.2 Literature review strategy
The literature search utilised Pub Med and Google Scholar data bases, with
a period limit of January 1996 until December, 2016.The key words
strategy used were;
 ―Perimenopause, gynecological morbidity and adult women‖.
 ―Menopause, morbidity and adult women‖.
 ―Perimenopause, morbidity and India‖.
 ―Menopause, morbidity and adult women in India‖
 ―Menopause, health care seeking behaviour‖
Using the title to peg the relevance, the literature was listed and the associated
abstract was read. Relevant abstracts were chosen and searched for full text
availability through different sources. Full text articles that made a significant
contribution on the key topics were included. Some articles published before
6
1996 but were relevant to the issue were included in the body of literature
reviewed. Literature search process flow chart attached in Annexure I.
The identified materials were grouped on the basis of Studies Worldwide,
Studies in India, and Studies in Kerala. The literature was categorized on the
basis of;
i. Magnitude of the menopause related issues in global, Indian and
Kerala scenario.
ii. Short term effects and symptoms of menopause.
iii. Long term effects of menopause.
iv. Menopause and Quality of Life.
v. Determinants of menopause related morbidity and its correlates.
vi. Health seeking behaviour and related factors
vii. The concept of healthy menopause and recommendations regarding
it.
2.3. Menopause Related Symptoms and Determinants - Global

Scenario
There are racial or ethnic differences in symptom reporting and menopausal
status. A study was conducted to determine the variation in symptom occurrence
and reporting of mid aged women across different menopausal status among
14906 ethnically, racially, and culturally diverse women in the United States.
Controlling for age, education, health, and economic status, the classical
menopause symptoms like hot flushes and night sweats were more likely to be
reported by African-American women; whereas psychosomatic symptoms were
more likely to be reported by Caucasian women. Asian women were significantly
less likely to report vasomotor symptoms than any other ethnic group.
7
Perimenopausal women reported more psychosomatic symptoms than pre- or
postmenopausal women. Perimenopausal women, hormone users, and women
who had a surgical menopause reported significantly more vasomotor symptoms.
The factors associated with symptom reporting were education; self assessed
health (negative association) and economic constraints (positive association). The
symptoms depended not only on the physiologic changes during women‘s midlife
but also on ethnicity(Avis et al., 2001).
The prevalence of menopause related symptoms in nine Asian ethnic groups was
assessed in Pan-Asia menopause study; the symptoms were significantly different
between ethnic groups and in each ethnic group the proportion of women
reporting each symptom varied. Hot flush prevalence ranges from 5 percent of
Indonesian women to 100 percent in Vietnamese women. The commonest
menopausal symptom prevailing in Asian region were body and joint aches and
pains(Haines et al., 2005) .
A third of (33%) women experienced moderate to severe menopause related
symptoms in menopausal transition time or early post menopausal phase in a
study based in Greece. Four out of ten women in this group (40%) had moderate
to severe vasomotor symptoms, while 30 % of women were affected by more than
one symptom in different domains like psychological, psychosomatic, sexual and
vasomotor. Early age at menopause had a positive relation with the prevalence of
menopause related morbidity(Grigoriou et al., 2013).
A study in Sweden among a large sample of middle aged women identified the
determinants of menopause related symptoms such as sociodemographic
characteristics, life style, and other health problems. It also laid emphasis on
8
importance of considering these factors in understanding menopause related
symptoms as they have a direct and modifiable effect on existence of menopause
related symptoms(Li et al., 2003).
A nested cross sectional study conducted in Brazil in a multi ethnic group of
women to examine the association between psychiatric disorders in different
phases of menopause with physical, psychological menopause related symptoms,
using a standardized tool found that women in menopausal transition showed
higher rates of vasomotor symptoms and vaginal dryness with significant
associations with minor psychiatric disorder. The same study found that memory
loss was associated with menopausal transition and perimenopause, which has a
positive relation with minor psychiatric disorders. The cumulative factors
resulting from menopause with low educational status is an indicator of minor
psychiatric ailments; low sociodemographics and psychological factors leading to
more non specific somatic and psychological symptoms. The study recommended
educational intervention and special focus on critical window of menopausal
transition(Oppermann et al., 2012).
Another study among 356 participants in Malaysia in the age group 40-65 years
using a modified menopause rating scale found that 35%-45% postmenopausal
women reported major symptoms like joint and muscular discomfort, physical and
mental exhaustion, anxiety, depressive mood, irritability. The symptoms in
perimenopause and post menopause had statistically significant differences when
compared to premenopausal women. Post menopausal women experienced more
urogenital issues (Rahman et al., 2010).
9
Another study conducted in Kawasaki, Japan in 1998 using a self administered
questionnaire about menopausal symptoms among women who were 50 years or
more found that four menopause related symptoms, viz, hot flushes, sweats,
depression and insomnia were more prevalent among post-menopausal women.
These four symptoms were also associated with socio psychological and life style
factors and BMI(Ishizuka et al., 2008).
2.4 Menopause related symptoms and determinants-Indian

Scenario
The proportion of women in menopause status across age groups varied across the
states of India. Premature menopause in the age group 35-39 was high in states
like Andhra Pradesh (22.1per cent), Gujarat (10.7 per cent) and Karnataka (10.6
per cent). To some extent, variation in premature menopause can be explained by
socio-economic, demographic, nutritional and reproduction-related variables.
Women who have started childbearing early and women who had no children also
reach menopause early. As India is still characterised by a large number of
illiterate women with low age at marriage and early child bearing and with poor
nutritional levels, the problem of premature menopause may continue to be a
burden in the future too (Syamala and Sivakami, 2005).
Cultural factors influencing women‘s physical and psychological health varied
across societies. Attitudes towards menopause may be related to different cultural
practices and it also depends on the social construction of menopause.
Menopausal transition is the stage at which the accumulated risk factors can lead
to chronic diseases and disability. Unless women take preventive care, the burden
of disease may be very high in the later ages(Meeta, 2008). Individual variations
in menopausal symptoms were linked to rural urban settings and the associated
10
cultural beliefs. Any analysis of menopausal symptoms reporting in India should
take cognisance of this(Kumar Mishra, 2011).
A Pan Indian Study conducted across 21 cities among 2184 women in menopausal
transition and post menopausal found that the mean menopausal age of the Indian
women was 45.59 years (including women whose menopause was induced) and
the average age at natural menopause of the Indian woman was 46.2 years. Age at
menopause in different regions of India was as follows: East 45.1 years, West
45.5years, North 45 years, South 44.7 years, and Central region 43.1 years.
Higher education, high socioeconomic status with better nutritional status,
multiple reproductive choices, low stress experience, access to better heath
resources and medical care, longer marriage duration were positively associated
with late age at menopause(Ahuja, 2016).
In India, the most common reported menopause related symptoms were urogenital
symptoms, fatigue, weakness, body aches, and pains, hot flushes, mood swings,
and sexual dysfunction. A study conducted in West Bengal among women aged
40 and 55 years, who had attained natural menopause, suggested that menopausal
health of women is influenced by menstrual, reproductive history,
sociodemographic variables, lifestyle, genetic and access to adequate health care.
The study determined that variation the that exists in the menopausal experience
and its sociodemographic and reproductive factors can be related to difference in
ethnicity (Dasgupta et al., 2015).
A cross sectional study in Jammu among women of 40 years of age and above
belonging to middle socioeconomic status aimed to evaluate menopausal
symptoms in post menopausal women and its association with age and mean
11
duration since menopause in three age strata. Fatigue and lack of energy, head
ache, hot flushes, cold sweats, and weight gain were the most common symptoms
reported. The most frequent menopausal symptoms among those aged 40-44 with
lesser duration since menopause were fatigue, lack of energy, headache, hot
flushes, cold sweats, excitability, anxiety, numbness, tingling. In addition to these
symptoms weight gain, irritability and nervousness were reported commonly by
women in the ages 45 to 50 years. Rheumatic pains, fatigue, lack of energy,
headache, pain in back, forgetfulness, neck and skull pain, sleep disturbance and
depression were frequent symptoms among those aged 50 years and more
(Sharma et al.2007).
A study in Bihar in 2013, conducted to compare the frequency and severity of
menopausal symptoms during peri menopausal and post menopausal period
estimated the mean age of menopause to be 45.29 years. There was a significant
difference between symptoms experienced in terms of frequency and severity
among perimenopausal women and post menopausal women. The most common
symptoms were fatigue, depression, anxiety, hot flushes and sexual disturbances
in perimenopausal period and urogenital symptoms, muscle and joint pain, fatigue
for postmenopausal women(Ahsan et al., 2015).
A cross sectional study in Agra found that the mean age at menopause was 48.2
years, and that the women in the menopause experienced more than one symptom.
Muscle and joint pains were reported by 70% of women and mood swings were
present for 65% of the women with symptoms. Close to half of the women (45%)
had hot flushes and excessive sweating, 44% had changes in sexual desire, 41%
12
cases had dryness of vagina, 35% had urinary symptoms, and 11% had anxiety
and irritability(Garg et al., 2015).
A study in Karnataka mean to assess the menopause related health problems
among pre and post menopausal women and the relationship of menopause status
with family composition, menstrual history, presenting health problem, past
history, family history, personal history and dietary history found the mean age at
menopause to be 45.32 years. Muscle and joint pain, vasomotor symptoms,
urological symptoms, vulvovaginal symptoms, hot flushes, were experienced by
post menopausal women(Avin Alva and Chethan, 2016).
A study in the urban slum of Mysore undertaken in 2015 found that 88 percent of
women attained natural menopause and that for 12 percent of the women,
menopause was induced, mainly surgical. Almost all the women in the study
(95%) had one or more symptoms of menopause. The most common symptoms
reported were joint and muscular discomfort, physical and mental exhaustion,
depression, irritability, and vasomotor symptoms. There was a significant positive
correlation between postmenopausal symptoms and age(Kulkarni et al., 2016).
Another study in Himachal Pradesh found that the majority of the women had a
positive attitude towards menopause and that the number of symptoms increased
with age. The most common co-morbidity reported by the study participants were
hypertension and arthritis(Mahajan et al., 2012).
2.5 Menopause and Long term health Issues.
There are ethnic, cultural, social differences between features of menopause
between Asian and Western regions and within Asian region (among individual
countries).Asian countries are experiencing transition in different fields like
13
economic changes, urbanization, and increased life expectancy. These situations
contribute to predisposing consequences of menopause, like chronic diseases and
this should sent out alarm signals to the public health system(Baber, 2014).
Menopause was associated with increased risk for metabolic syndrome which is
characterized by insulin resistance, altered glucose tolerance, or diabetes,
dislipidemia-(low HDL, high LDL, and high triglycerides), hypertension, and
central obesity. The sites of cancer incidence among midlife women were breast,
cervix, ovary, and endometrial(Unni, 2010).
A clinical cross sectional study was conducted in hospital Gynaecologic
endocrinology Unit in Brazil with 97 post menopausal women in the age group
45 to 65 years, to evaluate the prevalence of subclinical cardio vascular disease
risk and its association with hormonal levels and demographic, anthropometric
and metabolic variables. The study reported moderately high prevalence of
subclinical atherosclerosis (using Framingham General Cardiovascular Risk
Score) and, high BMI, age and endogenous estrogens, as well as cardiovascular
risk factors such as blood pressure and LDL cholesterol all of which may lead to
subclinical CVD in postmenopausal women(Maturana et al., 2015).
One study conducted in Prague with a randomly selected population of 909
women aged 45-54 years (women in reproductive age and post menopause) to
compare the effects of insulin resistance as a part of metabolic syndrome which
increases during menopause showed that transition to menopause is an associated
risk factor for manifestation of the Metabolic syndrome in middle aged women.
Visceral (abdominal) obesity which can be assessed by the waist circumference is
one of the easily measured components of metabolic syndrome. The study is
14
indicative of the importance of the preventive aspects of metabolic syndrome
manifestation in the menopause transition by reducing the risk in the reproductive
age group, which may be accelerated by menopause(Lejsková et al., 2011).
In case of association between the extent of diabetes and low hormonal levels
(FSH) during postmenopausal period, a study done with a subsample from a
cross-sectional survey on prevalence of metabolic diseases and risk factors in East
China, with biochemical clinical and anthropometric measurement showed a
significant association between post menopausal low FSH and prediabetes and
post diabetic stages. It was partially explained by adiposity and insulin
resistance(Wang et al., 2016). A study conducted to assess the possible
association between poverty and the prevalence of obesity and oophorectomy in a
population of post menopausal women compared reproductive history such as age
at menarche, age at menopause, fertile years, and number of pregnancies, breast
feeding and use of hormonal replacement therapy in 1225 post menopausal
Caucasian women in Spain. The age at menarche was earlier in low
socioeconomic status women, obesity, the number of pregnancies and number of
abortions, frequency of breast feeding and prevalence of bilateral oophorectomy
were also higher among women with low socio economic status(Navarro et al.,
2010).
Another study in Brazil which aimed to examine the association of metabolic
syndrome and sexual function in a cohort of women who were attending the
menopausal clinic; found no association between sexual dysfunction and
components of metabolic syndrome in women aged 40-60 years(Politano et al.,
2015).
15
A study conducted in Delhi, to compare bone mineral density and its variation in
pre and post menopausal women indicated a high positive correlation between
bone mineral density at spine and femur neck with BMI in both pre and
postmenopausal groups. Age and menopause were significantly associated with
bone mineral density in spine. On an average, premenopausal women were more
likely to have dietary Calcium intake than in postmenopausal women and this
difference was statistically significant. This study emphasised on the need to
improve awareness about bone health and recommended early interventions in the
midlife to reduce the morbidity of osteoporosis(Mittal et al., 2011). Women
between the ages 40-60 years were suffering from Osteopenia (35%-40%) and
osteoporosis (8%-30 %). These were more common among urban women than
rural women(Gandhi and Shukla, 2005).
A cross sectional survey in Netherlands studied the impact of menopausal
symptoms on work ability of women in the ages44-60 years by mailing Green
climacteric scale and Work ability Index to female employers of one home care
organization and one hospital. Psychological and somatic domains of the Greene
climacteric scale and low level of education were found to negatively influence
work ability(Geukes et al., 2012).
2.6 Metabolic Syndrome and Menopause
Metabolic syndrome is considered as one of the epidemics with two emerging
components of type 2 diabetes mellitus and cardiovascular disease in 21st
century(Tavares et al., 2015). The women in menopause stages show very high
profile of metabolic syndrome components worldwide. During menopause the
pattern of hormone secretion changes and gradually causes fat accumulation in
16
visceral tissues of abdomen and as a result, central obesity. A fourfold increase in
incidence of cardio vascular diseases risks in postmenopausal period as
evidenced by Framingham(Carr, 2003) .The prevalence of metabolic syndrome
was higher in post menopausal women even after adjusting for age(Heidari et
al., 2010).
Longitudinal studies in ‗Study of Women‘s Health Across the Nation‘ showed an
increase in prevalence of metabolic syndrome irrespective of chorological aging
in menopausal stages and evidence of ovarian aging contribute changes in body
composition and waist circumference(Sowers et al., 2007 ; Janssen, 2008).
Menopause can be a predictor of metabolic syndrome in women(Ben Ali et al.,
2014). A study conducted in Western India shows high prevalence of metabolic
syndrome in post menopausal women(Vaidya et al., 2010). The prevalence
estimated in post menopausal women was 48 percent, 1.7 times more than pre
menopausal women in another study(Singh and Sinha, 2016).
According to International Diabetes Federation(IDF, 2006), for a person to be
defined as having the metabolic syndrome they must have central obesity, defined
as waist circumference more than or equal to 80 cm in South Asian woman, plus
any two of the following four factors:
a) Raised triglycerides (value≥ 150 mg/dL (1.7 mmol/ L) or specific treatment
for this lipid abnormality.
b) Reduced HDL cholesterol (< 40 mg/dL (1.03mmol/L) in male‘s and
< 50 mg/dL (1.29mmol/L) in females or specific treatment for this lipid
abnormality.
17
c) Raised blood pressure, systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg
or treatment of previously diagnosed hypertension.
d) Raised fasting plasma glucose (FPG) ≥ 100 mg/dL (5.6 mmol/L), or
previously diagnosed type 2 diabetes.
2.7 Menopause and Quality of Life
Researchers studied the satisfaction with quality of life of menopausal women in
urban areas Beijing, China using Menopause specific quality of life questionnaire
among 353 women aged 40-60 years, during menopausal transition and post
menopausal periods. Menopausal symptoms can be influenced by a combination
of physical changes, social-cultural influences and individual perception. The
study indicated that the menopause women‘s quality of life was affected by
vasomotor and sexual symptoms and the most frequent symptoms were poor
memory; and this symptom experience was more severe among post menopausal
women in urban areas(Chen et al., 2007).
Afro Colombian was more vulnerable to menopausal somatic and psychological
symptoms, and low quality of life. Black race, low socioeconomic status, lower
educational status, obesity of Afro-Hispanic women in Latin America were the
risk factors for symptoms of somatic (mostly influenced by heart discomfort and
muscle and joint problems) and psychological problems(Monterrosa et al.,
2008). It was evidenced in a study conducted among Afro and non Afro Hispanic
Colombian menopausal women which aims to compare the frequency and severity
of menopausal symptoms using Menopause Rating Scale in 578 women matched
for age, parity and hormone therapy.
18
Anxiety and depression are common symptoms related to menopause which
affects the quality of life. A study conducted in Japan to assess the correlation
between somatic and psychological symptoms of menopause and effect of
insomnia on anxiety and depression found that psychological symptoms were
more prevalent, and that anxiety caused difficulty in initiating sleep and depression
resulted in non- restorative sleep. Insomnia was highly prevalent among peri- and
post-menopausal female patients in this clinical setting(Terauchi et al., 2012).
2.8 Health seeking behaviour and menopause
A cross sectional study which aims to find out the pattern of health care seeking
behaviour for reproductive health related problems in Beirut, Lebanon showed
that around one third of the participants with accessibility to public subsidized
care , didn‘t sought care for reproductive health problems because of financial
constrains. The determinants of positive health seeking behaviour for women
were younger ages, severity of the health issue, and presence of health insurance.
More than half of the women sought care in private sector and determinants of
public sector preference were financial crisis, and higher parity(El-Kak et al.,
2009).
A study conducted in Aligarh, India to find out the major health problems of post
menopausal women and assess the level of knowledge, attitude practice of post
menopausal women in health care seeking and determine the barriers of health
care seeking found that the rural urban difference in seeking health care. Rural
population has no access to health services. Major barrier in seeking health care
were distance, lack of awareness, lack of trust, lack of a companion, preference to
home remedies and financial problems. The most women were unwilling to
19
discuss their problems because they perceived the problems as a part of ageing
and it is common everywhere(Khan et al., 2016).
There were multiple factors were associated with care seeking of the women for
reproductive health related issues. The barriers of health care seeking can be varied
in different situation, can be cultural such as caste, religion; demographic such as
age, education, family; economic such as household wealth, dependency; social
such as empowerment, autonomy and demand side such as perception of severity
of the problem(Rani and Bonu, 2003).
2.9 Concept of healthy menopause

2.9.1. A conceptual framework for healthy menopause
Multiple factors are responsible for the perception of the women regarding
menopause and what they address with regard to symptoms. Menopause and
menopausal transition are an important opportunity to encourage health screening
among women. It provides a chance to encourage preventive health behaviour. A
healthy lifestyle with nutritional supplementation, exercise, adequate sunshine and
sleep time can be emphasized in all menopausal women presenting with
symptoms. Second, the health care workers should be sensitized to identify
menopausal women and utilize every contact to screen them for symptoms,
examine and investigate for problems. Culturally appropriate individualized care
and promoting healthy lifestyle in the physiologic transition may ensure a good
quality of life for midlife women. The researchers from all the disciplines should
work together for better understanding of women‘s health across cultures and
boundaries(Malla and Tuteja, 2014 , Richard-Davis and Wellons, 2013). Some
studies recommended that the health care systems role in taking care of high risk
group specifically focused on obesity of women even there is free provision of
20
health care in the country (Navarro et al., 2010) and establishment of
menopausal clinic with in current primary health care system(Avin Alva and
Chethan, 2016).
Good health in the menopausal period can be conceptualised from different
perspectives including the woman‘s own perspective, that of the society, or from
the perspective of a clinic or from that of a public health(Jaspers et al., 2015).
21
CHAPTER 3
METHODOLOGY
3.1. Study Design
The objectives of the study were to determine the magnitude of menopause related
symptoms, health care seeking behaviour, and associated factors in representative
sample from the community. As the researcher is looking to describe the events of
self reported menopause related symptoms in women in different menopausal
status at a time, and associated factors in a community structure, descriptive study
was selected as first choice of study design. This helped in capturing multiple
variables at a time and will enable the estimation of the magnitude of the problem.
Keeping in mind the objectives and time constraints for the research, a community
based cross sectional study was selected as a study design.
3.2 Study setting
The study was conducted in Kollam district, Kerala. Kollam district constitutes
about 6.4 percent of total area of Kerala State. Population in the District
constitutes about 7.89 percent of State population (2635375in number) and
population density is 1056 per square kilometre which is higher than the state
average. Literacy rate in the District was 93.8 percent and female literacy was 92
percent, which is the 8th position in State.(Economics and Statistics Department,
2013).The number of females per 1000 males in the District is 1113 and it is more
than state average. The proportion of urban population in the district is about 46
22
percent which is more or less the same at that in the Kerala state which is 47.7
percent(Census, 2011b).
3.3 Study Population
Target Population was the women in state of Kerala as this study aimed to
generalize the findings. Source population was the women in the age group of 35-
60 years who were either in menopausal transition phase or postmenopausal
period in the community in Kollam District. The study population included
women 35-60 years old either in menopausal transition phase and post
menopausal period who provided formal consent for participating in the study.
3.4 Sample size estimation
A study conducted in Idukki District to assess menopause related problems
among women reported the prevalence e of the classical menopausal symptoms
as 46.7 %(Subrahmanyam and Padmaja, 2016).The sample size for the present
study was calculated using this known prevalence. Sample size was estimated to
be 421, using the formula 3.84*p(1-p)/d2 where p= 46.7% ( prevalence of
classical menopause related symptom in kerala study 46.7 %) with 5% precision
and design effect 1, and 10 % non-response rate. As Kollam District has 54.95
percent rural and 45.05 percent urban population the study population was
segmented in keeping with this proportion as 240 and 190 respectively. Thus, the
sample size estimated for the present study was 430(240 rural women +190 urban
women).
3.5. Sample selection procedure
Multistage stratified random sampling was done to ensure allocation across rural
and urban areas. The rural representative sample was selected from Community
23
development blocks and urban representative sample was selected from
Corporation and Municipality of Kollam District. The rural and urban
participation was illustrated in figure 3.1.
U RURAL (240) U URBAN (190)
11 CD Blocks (68 3 3Muncipality 1Corporation

11 Panchayats-1274
CD Blocks (68 Panchayats-1274 wards)(102wards) (55 wards)
wards) n=240 n=100 n=90
11 CD Blocks (68 Panchayats-1274 wards)
Figure 3.1.Rural and urban participation
Kollam District consists of one corporation, three municipalities and 11 Block
Panchayats. Kollam Corporation is having 55 wards; three municipalities
(Karunagappally, Punalur and Paravoor) having total of 102 municipal wards,
representing the urban population.11 Block Panchayats having 69 Grama
Panchayats with 1274 wards, represent the rural population. (Economics and
Statistics Department, 2013; Kollam District official website).
Among 11 block Panchayats three Panchayats were selected randomly using Open
Epi version 3.01 Software from the list of all block Panchayats(LSG, Kerala,
2017).
The name and number of Panchayat wards was obtained from local self
government website(LSG, Kerala, 2017).The list of all wards in the
24
corporation(Kollam Muncipal Corporation, 2017) and municipality was obtained
from the corresponding official websites(Paravur Municipality; Punalur
Municipality; Karunagappally Municipality).
Random
11 CD selection3 Block 13-14 eligible
blocks-69 panchayats; from
women from each
Panchayats each Block 3
panchayat(total-9) ward to constitute
-1274
and 2 240 rural women.
wards
wards(total18 )
Random selection 10-11 eligible

3
of 3 wards from women from each
Muncipality-
each ward to constitute
102 wards
Muncipality(total 9) 100 urban women.
1 10 eligible women
corporati Random selection
from each ward to
on- of 9 Corporation
constitute 90 urban
wards
55 wards women.
Figure 3.2.Outline for Sample population recruitment.
The Randomly selected Block Panchayats were Chittumala Block, Kottarakkara

Block and Oachira Block.
1. Chittumula Block having 8 Grama Panchayats- random selections of 3
Panchayat and 2 wards from each Panchayat (total of 6 wards from each
Panchayat and 13-14 study participants from each ward selected by systematic
random sampling of household.
Chittumulablock-8 1.Mandrothuruth-12 1.Ward no.7 &11

Panchayat-Random 2.Penayam-16 2.Ward no.2&14
selection of 3 3.Trikkadavoor-18 3.Ward no.4&10
Figure3.3.Description of Chittumala Block-Gramapanchayat wards
25
2. Kottarakkara block having 6 Panchayats-random selection of 3 Panchayat
and 2 wards from each Panchayat (total 6 wards from each block Panchayat and
13-14 study participants selected from each ward by systematic random sampling
of household.
1.Veliyam-19 1.Ward no.1&3

Kottarakkara block- 6
2.Ezhukone-16 2.Ward no.14&16
Panhayath
3.Pooyappally-18 3.Ward no.7&10
Figure3.4.Description of KottakkaraBlock-Gramapanchayat wards
3. Oachira block having 6 Panchayats- random selection of 3 Panchayat and 2

wards from each Panchayat (total 6 wards from each block Panchayat and 13-14
study participants selected from ward by systematic random sampling of
household.
1.Kulasekharapuram-23 1.Ward no.1 &21

Oachira block-6
2.Oachira-17 2.ward no.3&9
panchayath
3.Thodiyoor-23 3.Ward no.9&17
Figure 3.5.Description of Oachira Block –Gramapanchayat wards
Among three Municipalities (Karunagappally, Punalur and Paravoor) three
wards were selected randomly from each municipality to constitute 9 municipal
wards altogether, 10-11 eligible women were selected from each ward to obtain
100 women from the municipal ward. The wards selected in Karunagappally
municipal wards were, Manpozhil, Kannetti and Pakal veedu(Karunagappally
Municipality). The wards from Punalur Muncipality were Arampunna, Kakkode,
26
and Paravattom(Punalur Municipality) The wards from Paravoor Muncipality
included in the study were Attinpuram, Kurandikkulam, and Karamandal(Paravur
Municipality).
From Kollam Corporation,55 wards random selection of 9 wards, and selection
of 10 women from each ward to get 90 urban eligible participants.9 wards are;
Maruthadi, Neeravil, Uliyakovil, Kavanadu, Mathilil, Asramam, Bharanikav,
Thangassery, Thirumullavaram.(Kollam Municipal Corporation, 2017)
Table 3.1.Urban Sample Selection wards list

Urban Population
Municipality Corporation
Karunagappally Punalur Paravoor wards Kollam wards
Wards wards
Manpozhil Arampunna Attinpuram Maruthadi
Neeravil
Kannetti Kakkode Kurandikkulam Uliyakovil
Kavanadu
Pakal veedu Paravattom. Karamandal Mathilil
Asramam
Bharanikav
Thangassery
Thirumullavaram
10-11 participants from each wards .Total of 100 10 participants from
participants. each ward. Total of
90 participants.
3.6. Subject Selection Procedure
At the centre of the selected wards, the main junction was located and by using
pen rotating method, the first household of randomly selected road was
approached for data collection. Systematic random sampling method used for the
selection of the household, every third household was selected.. If there was no
27
eligible participant in the first household next third household selected for the
study. If the women in age group 35-60 were not available at home at the time of
visit, the Principal Investigator tried to contact them by phone for the willingness
and availability of time for the study after introducing the topic to them. If the
woman was willing to participate in the study, the principal investigator visited
the household with prior appointment. In case of non response or non availability
(even after second attempt) substitution done to complete the required sample
size.
If there were more than one eligible woman in the household at the time of the
study, during the listing process, after considering the inclusion and exclusion
criteria, one women selected by Kish next birthday method(Salmon and Nichols,
1983). The woman whose birthday is coming recent future taken as study
participant from that household. .If the selected woman did not met the inclusion
criteria according to the screening questionnaire, and then no further questions
were asked. Another household was visited to recruit yet another participant for
the study.
3.7. Inclusion and Exclusion criteria
3.7.1 Inclusion criteria
The women in the age group 35-60 years old who is in menopausal transition or
post menopausal phase and /or attained menopause either naturally or induced
were included in the study.
3.7.2 Exclusion criteria
Women who were pregnant or lactating or had recent abortion (with in 3 months)
or critically ill or currently receiving hormone therapy or oral contraceptives were
28
excluded from the study. Women who were not willing to give consent also
excluded from the study.
3.7.3 Justification for the age group 35 to 60 years old.
According to National Family Health Survey 3, there were around 11.2% in the
age group 30-39 who attained menopause in India among 30-49 years of age
(NFHS-3, 2007) .As it is a significant percentage of menopausal women, the
present study participants will be women aged 35 years and more. Late post
menopausal symptom reporting is different from early post menopausal period.
After 60 years, ageing related factors may also influence the symptom reporting
and it may affect the accuracy of the study. So the age inclusion was restricted to
60 years.
3.8. Ascertainment of Menopausal Status
Stages of Reproductive Aging Workshop (STRAW) revised criteria and
nomenclature are used for ascertainment of menopause and inclusion of the
women in the study. It provided a comprehensive basis for staging since there
were more complexities on ascertainment of menopause explained in figure3.6.
The STRAW criteria are considered as the gold standard for assessing
menopausal stages.
29
Figure 3.6.Ascertaintment of menopausal Stages in the study (STRAW+10
staging system for reproductive aging in women. Source; (Harlow et al., 2012).
30
The principle criteria proposed by STRAW giving a clear classification unique
stage in women. Early menopausal transition (stage -2) is marked by variability in
menstrual cycle length, by persistence difference of 7 days or more in length of
consecutive cycles. Late menopausal transition (stage -1) is ascertained by
occurrence of amenorrhea of 60 days or longer. For current study early and late
post menopause stage are calculated as menopausal transition when meeting either
one of the above said criteria. Early post menopause stage (+1a, +1b, +1c) last
approximately 5 to 7 years, from the onset of final menstrual period (FMP-
retrospective amenorrhea for 12 months). Late post menopause (stage +2) is
beyond 5 years of FMP in which further changes in reproductive hormonal
function are limited and more of physical aging will be a concern(Harlow et al.,
2012).
3.9. Definitions of the menopausal stages;
3.9.1Menopause Transition
The term menopausal transition should be reserved for the time before the final
menstrual period when variability in the menstrual cycle is usually
increased(Utian, 1999).
3.9.2. Operational definition for menopausal transition (period) for this

study.
The last one to three year in which women missed menstrual period at least 2
consecutive cycles (more than 60 days) or any variability in duration and flow of
any one menstrual cycle in the absence of any known pathology, pregnancy and
lactation (or) women had irregular cycles in the past 3 months in the absence of
any pathology, in the age group of 35-60 years.
31
3.9.3. Post menopausal period
The term post menopause is defined as dating from the final menstrual period,
regardless of whether the menopause was induced or spontaneous (Utian, 1999).
3.9.4.Operational definition for this study-Post menopausal period (Chen et

al., 2008 ; Harlow et al., 2012 ; Sherman, 2005).
3.9.4. a. Early post menopause period in Women
Women who do not have menstrual period (amenorrhoea) in last 6 to 12
consecutive month, not due to medication or pregnancy or any other medical
condition (attained menopause) and within the period 5 year after the point of
menopause.(women without menstruation for last five years).
3.9.4. b. Late Post menopausal period in Women
Women, who attained menopause and the period after 5 years, without menstrual
cycle and within the age of 60 years old.
3.10. Data collection Procedure
Data collection done using a structured questionnaire and the adapted green
climacteric scale to assess menopause related symptoms. The interview was
conducted in local language, Malayalam and carried out by the principal
investigator herself for all the participants, at each eligible participant‘s residence
with minimal distractions and discomfort and assuring convenience and comfort.
A preliminary study was done among 12 women aged between 40-60 years old to
see the feasibility, inclusion of study subjects, in the community using structured
menopause related symptom questionnaire and interviews of 3 women to shape
the research project. The narratives of the women and analysis of data taken care
during development of research tool and design.
32
3.10.1. Research Tool
Interview schedule for women was categorized into eight sections. They were;
Section A Checklist before proceeding
Section B Screening Questionnaire, for selection of eligible woman
Section C Socio-demographic and economic data
Section D Reproductive Health History
Section E Other health history and waist circumference
measurement.
Section F Knowledge, Attitude and Perception regarding menopause
and related symptoms
Section G Menopause related symptoms-Green climacteric scale
questionnaire
Section H Health seeking for menopause related symptoms
3.10.1. a. Green Climacteric Scale;
Green Climacteric scale was adopted to assess menopause related symptoms in
this study. Green Climacteric Scale is a set of 21 questions gives a brief measure
of menopausal symptoms. The original Green Climacteric Scale has 21 questions
to elicit menopause related symptoms on the basis of severity of symptoms. It has
mainly four domains such as psychological(1-11), somatic (12-18), vasomotor(19-
20) and sexual(21).Psychological domains are divided into anxiety(1-6) and
depression(7-11).The scale measures the presence of each symptoms by rating
from not at all to extremely which ranges from 0-3 for each question in the scale.
Not at all = 0, A little = 1, Quite a bit = 2, extremely = 3.The total score can range
from 0 – 63.The higher score indicates that the higher the woman is bothered
about menopause related symptoms. (Greene, 1998; Hakimi et al., 2010 ;
Bindhu et al., 2013 ; Chattha et al., 2008).
33
Scoring
Total Green Climacteric Score 0=nil,1-9=mild,10-19=moderate, 20 &
above=severe.
Psychological subscale score 0=nil, 1-3=mild, 4-9=moderate, 10 or more=severe.
Somatic subscale score 0=nil, 1= mild, 2-3= moderate, 4 or more = severe.
Vasomotor subscale score 0=nil, 1=mild, 2=moderate, 3 and more=severe.
Sexual subscale score 0= nil, 1=Mild, 2=Moderate, 3=Severe.
Table 3.2. Green Climacteric Scale Descriptions
Scale Symptom Domain Number of Item Number Score

Items range
Psychological-anxiety 6 1-6 0 - 18
Psychological-depression 5 7-11 0- 15
Somatic 7 12-18 0-21
Vasomotor 2 19.20 0-6
Sexual dysfunction 1 21 0-3
Validation of Green Climacteric Scale
Linguistic validation and cognitive debriefing were done for Malayalam translated
version of the Green Climacteric scale in 10 post menopausal woman in
community areas of Kollam. This resulted in revising the translations for
questions 14 and 17. Clear specifications were given for the questions 8 and 11 of
the scale. The translated version of the scale was given to two Gynaecologists
each from private and public health care settings to get expert opinion about
validity of scale in addressing the common menopausal symptoms in their clients
based on their practice in the hospital.
34
3.10.1. b Waist Circumference measurement Protocol:
The WHO STEP wise Approach to Surveillance (STEPS) provides a simple
standardized method waist circumference adopted. The protocol for measuring
waist circumference was the measurement by approximate midpoint between the
lower margin of the last palpable rib and the top of the iliac crest (World Health
Organization, 2011).The cut off value for South Asian woman will be less than or
equal to 80 cm.
Figure 3.7.Procedure of waist circumference measurement

Measuring tape position for abdominal (waist) circumference. Source:(CDC, 2007)
Procedure of waist circumference measurement in the community: During
waist circumference measurement the PI made sure the comfort and privacy of the
participant. Waist circumference was measured with accuracy by requesting the
study participant to avoid heavy dress during measurement around abdomen.
3.10.1. c. Variables in the study

The dependent variable menopause related symptoms was measured using Green
climacteric scale with 21 questions in four domains. The health seeking behaviour
with place of health care seeking was captured using structured questionnaire.
35
Independent variables in the study
1. Age of the participant (in years): The completed age of the participants was
recorded.
2. Menopausal statuses
There were three categories of menopausal status such as menopausal transition,
early post menopause and late post menopause. The women were recruited for the
study after ascertainment of menopausal status using the screening questionnaire.
3. Type of menopause
The type of menopause is an important independent variable in the study. It was
categorized into four groups as natural menopause, induced by surgery, induced
by any other pathology and induced by radiation or chemotherapy.
4. Age at menopause
The age at menopause and average age at menopause were elicited from the
participant to see any relationship with menopause related symptoms.
5. Socioeconomic characteristics
The place of residence, highest educational attainment of the participants,
occupational status, marital status, caste and economic status of the participants
were assessed to examine the relationship between menopause related symptoms
and economic status. These variables were selected using the NSSO 66th round
inputs(Department of Economics and Statistics, 2014).
Note; Economic status index: a family was said to belong to high SES if they own
their house with paved tiles in the courtyard and concrete roof with tiled floor
with designed landscape +average spending of the house 9000 INR and above +
having more than three electrical appliances.
36
A family was said to belong to middle SES if they own house with concrete roof
but floor is only cemented/red oxide+ average monthly spending of 5000-9000
and having at least two electrical appliances.
A family was said to belong to low SES if they rented or own house with roof
tiled/sheet/leaf and floor which is not finely cemented (unpolished floor)+
average monthly spending of 1500-5000 + having one or not having any
electronic appliances .
6. Presence of Socio-economic support
Family support, social support and economic independence were assessed in this
category.
Defining Social support: A woman who was having membership in Kudumbasree/
Sreesakthi/ ayalkootam, etc. Was considered as having social support.
Defining family support in the study: a women who was having a supportive hand
in the family and permanently residing with her (usually the husband and children
more than 14 years old).
Defining economic independence: A women who was having direct economic
income to her own hand either from occupation or pension fund or any other
welfare fund was considered as economically independent.
7. Life style factors- physical activities and diet
The pattern of physical activity, dietary choice and control in consuming high fat
high sugar diet were collected to examine the association with dependent variable.
8. Reproductive health histories
The experience of any menstrual irregularity, number of pregnancy, number of
delivery, ever had any complication during delivery, history on contraceptive use,
37
ever diagnosed gynecological morbidity, ever underwent any therapeutic
gynecological surgery and ever had any gynecological cancer were asked to
examine the association with outcome variable.
9. Other health history
Self reported presence of high blood pressure, diabetes mellitus, high cholesterol
and presence of any other medical condition as general were collected to examine
the association with menopause related symptoms.
10. Health seeking pattern for gynecological morbidity and medical condition.
Health seeking pattern for gynecological morbidity, medical condition, place of
health seeking, preference for health seeking were collected to examine the
relationship with health seeking behaviour for menopause related symptoms.
3.10.2. Data collection in the field
The data collection was undertaken from 20th June to 31st August 2017, by the
principal investigator. There were two screening questionnaire to recruit the
eligible participants for the study. Knowledge, attitude, perception questionnaire
failed to get objective measurement because it was loaded by menopause related
symptom questionnaire. Therefore, this section was not included in final data
analysis.
3.11. Ethical considerations

Written informed consent obtained from the subject prior to the start of the
interview. In the case of women who were not be able to give written informed
consent, verbal consent was obtained in the presence of an independent witness
who would sign. Privacy and confidentiality of all the information collected was
ensured.
38
The study was approved by Institutional Ethics Committee, Sree Chitra Tirunal
Institute for Medical Science and Technology before commencement.
(Reference number: SCT/IEC/1042/MAY-2017).
3.12. Data entry and analysis
The data was entered in Epidata and analysed by IBM SPSS version 21 Software.
The data has been presented using descriptive statistics for the prevalence of
menopause related symptoms, health seeking behaviour and other variables.
Bivariate analyses have been done to examine the relationship between predictor
and outcome variable.
3.13. Data storage, transfer and management.
The data collected was stored in the computer with password encryption of the
file. The hard copy of the filled interview schedule, consent form have been
strictly confined to personal locker of the principal investigator .After three year,
the copies will be destroyed. Only the final report will be shared with the
concerned persons, authorities scientific or Government bodies.
3.14. Plan for dissemination
The final thesis report will be submitted to the SCTIMST for the award of the
MPH degree. The conclusions emerging from the study will be presented to
experts in the field for comments and to initiate more research. The findings will
be shared with health department for implementing new actions and policy
changes and will be presented in scientific conferences. The final thesis report
will be published as working paper.
39
3.15. Expected outcomes
The study results can be used to provide recommendations to the existing health
care programmes or to recommend policy level changes as needed.
40
CHAPTER 4
RESULTS
4.1. Introduction
In all, 714 households were visited to identify 430 eligible participants for this
study. Of these 430 eligible participants, 4 refused to consent, and 6 could not be
included in the analysis because of age mismatch, discontinuation during
interview and incomplete data. The reasons for refusing consent were
inconvenience expressed by the participant for exploring their identifiers, the
study not bringing any direct benefit for them, and time constrains. One
participant was emotionally unstable because of recent negative event in the
family, so the interviewer did not ask for consent. This resulted in 420 eligible
participants being included in the analysis. The expected non-response rate was 10
percent, but the final observed non-response rate was only 2.33 percent. This
chapter presents the results of the analysis of the 420 eligible women.
The general description of the study participants in terms of their demographic,
socioeconomic characteristics and menopause status are in the first section of this
chapter. The study participants‘, reproductive health history, other health history,
presence of central obesity are included in the second section. The menopause
related symptoms of the women in the study sample was assessed using Green
Climacteric Scale (GCS). These results are reported in the third section. The
results of health seeking behaviour for the menopause related symptoms are
described in the fifth section. Knowledge, attitude and perceptions regarding
menopause and menopause related symptoms are described in the sixth section.
41
4.2. Participant profile
4.2.1 Profile of the participants by socio-economic characteristics
The participant profile in terms of socioeconomic characteristics is presented in
table 4.1. Rural participant formed 56.4 percentages of the study subjects. About a
third (33.8%) of the women in the study had primary or even lower levels of
education. The remaining two thirds had high school and above levels of
education. Any occupation with remuneration was considered for assessing
occupational status of the participant. The women who do not fulfil the above
criteria were considered as currently not working in three categories such as daily
wages, self employment, and salaried employment. Slightly more than half of the
women in the study were un-employed (51 %) and 26.4 percent earned daily
wages and only 12.1 percent earned a monthly salary. Close to seventy percent of
the women were currently married and others were widowed (25.7%).
A majority of the women in the study belonged to upper caste groups or other
backward castes (87.4%). The minority caste groups of scheduled caste and tribes
constituted just about 12 percent. Women in the study mostly belonged to middle
class in term of economic status. The participants‘ nature of support obtained
during the crucial menopausal period was also examined. While close to three
fifths of the women had family support (58.6%), far fewer women had social
support, just about two fifths (41.8%). More than half of them were economically
independent (55.2%).
42
Table 4.1. Profile of the participants by socio-economic characteristics,
Kollam district, Kerala. 2017
Variables N=420 (100%)

Place of residence
Rural 237 (56.4)
Urban 183 (43.6)
Educational status
No schooling 10 (2.4)
Primary 132 (31.4)
High school 191 (45.5)
Higher secondary, professional education and 87 (20.7)
above
Occupational status
No employment 215 (51.0)
Daily wages 111 (26.4)
Self employment 44 (10.4)
Monthly salary 51 (12.2)
Marital Status
Married 293 (69.8)
Unmarried 11 (2.6)
Widow 108 (25.7)
Divorced 6 (1.4)
Separated 2 ( 0.5)
Caste
SC/ST 51 (12.1)
General 173 (41.2)
OBC 194 (46.2)
Refused to answer 2 (0.5)
Socioeconomic index
Low SES 126 (30.0)
Middle SES 187 (44.5)
High SES 107 (25.5)
Family support
Have family support 246 (58.6)
Do not have family support 174 (41.4)
Social support
Have social support 176 (41.9)
Do not have social support 244 (58.1)
Economic Independence
Economic Independence 232 (55.2)
Economic dependence 188 (44.8)
43
4.2.2. Profile of participants by health related characteristics
The health profile of the participants is given in table 4.2. Nearly half of the
women had either mild to sedentary in terms of physical activity (51.7%). Quite a
significant number of the women reported moderate level of physical activity
(43.8%). Almost all were non-vegetarians (93.3%) and close to three fifths of
them had no control over either sugar or fat or both in their diet.
Only 15 percent of the women experienced menstrual irregularities. Fertility was
near universal; just less than five percent (4.3%) were nalliparous. Majority of the
women had one or two children (66.7%). One out of four women in the study had
undergone at least one c-section if not two. Close to 10 percent of the women
(9.3%) had experienced some form of complication (other than that requiring c-
section) during delivery. Nearly one out of 20 women in the study had
experienced a gynaecological morbidity (18.9%). There were nearly 1.4 percent
with some form of gynaecological cancers, including breast cancer, ovarian
cancer and cervical cancer.
The prevalence of self reported high blood pressure, type 2 Diabetes Mellitus and
high cholesterol in the sample population was 38.8 %, 26.7% and 35%
respectively. There were 14.5% women with other medical condition in study.
Presence of central obesity measured by waist circumference indicates that around
46% of the women in the study had a waist circumference of more than 80 cm.
44
Table 4.2. Profile of the participants by health related characteristics,
Kollam district, Kerala. 2017.
Variables N=420(100%)
Physical Activity
Sedentary 34 (8.1)
Mild Physical activity 183(43.6)
Moderate 184(43.8)
Severe physical activity 19(4.5)
Dietary choice
Vegetarian 28(6.7)
Non vegetarian 392(93.3)
Diet Control
Have control in consuming fat and sugar 169(40.2)
Do not have control in fat and sugar 233(55.5)
Have control over fat or sugar in the diet 18(4.3)
Previous menstrual irregularity

Have menstrual irregularity 63 (15)
Did not have menstrual irregularity 357(85)
Number of pregnancy
No pregnancy yet 18 (4.3)
One 46 (11)
Two 234 (55.7)
Three 91 (21.7)
Four and more 31 (7.3)
Number of delivery
One 42 (10)
Two 245(58.3)
Three 83 (19.8)
Four and more 32 (7.6)
Not applicable 18 (4.3)
Normal Vaginal delivery
One 50 (11.9)
Two 186 (44.3)
Three 70 (16.7)
Four 26 (6.2)
Five and more 3 (0.7)
Caesarean section delivery
One 48 (11.4)
Two 57(13.6)
Three 2 (0.5)
Complication during delivery
Had any complication 39 (9.3)
Did not had any complication 365 (86.9)
45
Table 4.2. Profile of the participants by health related characteristics,
Kollam district, Kerala. 2017. Cont’d…
Variable N = 420(100%)
Contraceptive history
Ever used 230 (54.8)
Never used 175 (41.5)
Gynecological Morbidity
Ever diagnosed as having a gynaecological 80 (18.9)
morbidity
Did not have a diagnosis of gynaecological 340 (81.1)
morbidity
Gynaecological Cancers
Brest cancer 3 (0.7)
Ovarian cancer 2 (0.5)
Cervical cancer 1 (0.2)
Other chronic conditions and risk factors
High Blood Pressure 163 (38.8)
Type 2 DM 112 (26.7)
High Cholesterol 147 (35.0)
Other medical conditions 61 (14.5)
Waist circumference>80 cm/Central obesity
(N=407) 189 (46.4)
4.2.3. Pattern of health seeking for gynecological morbidities and other

chronic health conditions
There were 80 participants who had a history of diagnosis of gynecological
morbidity. Treatment seeking for these and other health conditions is described in
table 4.3. Around 52 percent of them sought treatment in private secondary or
tertiary hospital. One women who had a condition of gynecological morbidity
sought care both in a public and a private health care facility. There were 268
participants among 420 who were reported to have at least one of the chronic
medical conditions such as hypertension, diabetes mellitus, high cholesterol or
other medical conditions including cancers. Among the 268 women 32.1 percent
sought care in private clinic, and 22.4 percent sought care in public primary health
centre.
46
Table.4.3.Pattern of health care seeking for gynaecological and other chronic
health conditions, Kollam district, Kerala, 2017.
Health problem and care seeking N (%)
Gynecological morbidity N=420 (100)
Yes 80 (19)
No 340 (81)
Health care seeking for gynecological morbidity N=80 (100)
Public secondary health centre 25 (31.3)
Public tertiary health centre 11 (13.8)
Private secondary or tertiary hospital 42 (52.5)
AYUSH 1 (1.3)
Both private and public 1 (1.3)
Any Chronic Medical Condition N=420 (100)
Yes 268 (63.8)
No 152 (36.2)
Health care seeking for medical condition N=268 (100)
Public primary health centre 60 (22.4)
Public secondary health centre 45 (16.8)
Public tertiary health centre 4 (1.5)
Private clinic 86 (32.1)
Private secondary or tertiary hospital 54 (20.1)
AYUSH 9 (3.4)
Both private and public 10 (3.7)
4.2.4. Profile of participants by age and nature of menopause
For purposes of this analysis, age was categorized into four categories based on
the distribution of the participants by age into less than 45 years, 45-49 years, 50-
54 years and 55 and above years of age. A majority of the participants were aged
55 and more. This information is tabulated in table 4.4.
The recruited study participants belonged to different menopause status. There
were 52.1 percent of women in late post menopause stage, 23.3 percent of the
women belonging to the early post menopausal category and 24.5 percent of the
women were in menopausal transition phase. While assessing the type of
menopause in post menopausal study participants, majority of the participant
attained it naturally, around 16 percentage of women attained menopause as a
result of surgical procedure for gynecological morbidities and 0.2 had reported to
47
had menopause either as a result of any pathology or induced by radiation or
chemotherapy.
Tab le 4.4. Profile of participants by age and nature of menopause, Kollam

district, Kerala, 2017.
Characteristics N (%)
Age category N=420 (100)
Less than 45 years 44 (10.5)
Age 45-49 years 86 (20.5)
Age 50-54 years 102 (24.3)
Age 55 and above 188 (44.8)
Menopause Status N=420 (100)

Menopause Transition 103 (24.5)
Early post menopause 98 (23.3)
Late post menopause 219 (52.1)
Type of Menopause N=317 (100%)

Natural Menopause 238 (75.07)
Induced by surgery 68 (21.45)
Induced by any pathology 10 (3.15)
Induced by radiation/chemotherapy 1 (0.32)
The average age at menopause for post menopausal women was estimated to be
46.1 years, with a standard deviation of 5.4 years. This was computed after
excluding 103 women who were in menopausal transition period. This was
because they had not yet attained menopause and including them could shift the
aver rage age at menopause lower, erroneously. Average age at natural
menopause was found to be 47.4 years with a standard deviation of 4.3 years,
calculated by excluding the women who were in menopausal transition and those
who reported to have had unnatural menopause like surgery
induced/pathology/radiation. The distribution of the age at natural menopause for
the women was more or less normal, with very little skew. The histogram of
average age at menopause and average age at natural menopause attached in
Annexure V.
48
4.3. Experience of menopause related symptoms
Menopause related symptoms were assessed using Green Climacteric Scale
(GCS) which has four domains such as psychological symptoms, physical or
somatic symptoms, vasomotor symptoms and sexual dysfunction (table 4.5).
There were 21 questions distributed among the four domains of the scale with an
option of 4 potential responses, not at all, mild, moderate to severe. Among 420
participants 56.7 percent of the women had severe psychological symptoms, 70.5
percent has severe physical symptoms, and 49.3 percent has severe vasomotor
symptoms. Among those who could report on their menopause symptoms (294
women), 28.6 percent had moderate sexual dysfunction. On the whole, 58.3
percent of the women were severely affected by menopause related symptoms.
These responses are represented in figure 4.2.
Table.4.5.Prevalence of menopause related symptoms by domains of the

green climacteric scale, Kollam, Kerala, 2017.
GCS Mild Moderate Severe Total Prevalence(%)
Domain n (%) n (%) n (%) (100%) with
95% CI
GCS total 52(12.4) 106(25.2) 245(58.3) 420 95.95 (93.73-97.54)
Psychologi 31(7.4) 96(22.9) 238(56.7) 420 86.90 (83.42-89.88)

cal
symptoms
7(1.7) 49(11.7) 296(70.5) 420 89.28(86.05-91.98)
Physical
symptoms
Vasomotor 5(1.2) 23(5.5) 207(49.3) 420 55.95(51.17-60.65)

symptoms
Sexual
dysfunctio 79 (26.9) 84(28.6) 30(10.2) 294* 65.64(60.08-70.91)
n score
*Not applicable/refused to answer/missing value omitted from analysis
49
Loss of interest in sex(N=294)
Night sweats(N=420)
Hot flushes(N=420)
Breathing difficulty(N=420)
Lossof feelinginhand or feet(N=420)
Muscle and Joint pain(N=420)
Headaches(N=420)
Numbness in body(N=420)
Pressure in head or body(N=420)
Feeling dizzy (N=420)

Mild
Irritability(N=420) Moderate
Severe
Crying spells(N=420)
Not at all
Feeling unhappy(N=420)
Loss of interest in things(N=420)
Feeling tired(N=420)
Difficulty in Concentratiing(N=420)
Attacks of panic(N=409)
Excitable(N=417)
Difficulty in sleeping(N=420)
Feeling tense or nervous(N=420)
Heart beating quickly(N=420)
0 20 40 60 80 100 120
Figure. 4.1. Distribution of Menopause Related Symptoms by GCS scale
50
Severity of menopause related symptoms by the specific menopausal stage and
domains of the GCS were assessed (table 4.6). Nearly two thirds of the women
(65.3) in post menopausal stage were having severe psychological symptoms.
There was no variation in physical or vasomotor symptoms among three
menopausal stages. There was a sharp increase in the percentage of women
reporting severe sexual dysfunction symptoms from those in menopause transition
to early and late menopause stages from 3.5 to 11.4% and 13.7% respectively.
Table 4.6. Severity of menopause related symptoms by menopause status and

domains of the green climacteric scale, Kollam, Kerala, 2017
GCS domain Severity Menopause Early post Late post Chi-
transition menopause menopause square p
value
Psychological
Severe 49(47.6) 46(46.9) 143(65.3) 0.001
Total (%) 103(100) 98(100) 219(100) 420(100)
Physical
Severe Severe 76(73.8) 65(66.3) 155(70.8) 0.506
Total (%) 103(100) 98(100) 219(100) 420(100)
Vasomotor
Severe Severe 55(53.4) 53(54.1) 99(45.2) 0.217
Total (%) 103(100) 98(100) 219(100) 420(100)
Sexual
dysfunction Severe 3(3.5) 8(11.4) 19(13.7) 0.048*
Total (%) 85(100) 70(100) 139(100) 294(100)
*One cell value is less than 5.
The GCS scale scores by domain were computed and this has been tabulated
along with the observed and expected ranges in table 4.7. The average score for
psychological anxiety subscale and depression subscale was 6.67 with standard
deviation 4.9 and 46 with standard deviation 3.5 respectively. The average score
for physical symptoms was 7.61 with standard deviation of 4.86.The average
score for vasomotor symptoms is 2.7 with standard deviation of 2.7 .The mean
score for sexual dysfunction was 1.1 with standard deviation of 1.0. The domains
51
of distress with respect to menopause related symptoms seem to be related to
psychological-anxiety related and also physical symptoms.
Table.4.7.Menopause Related Symptoms-Average scores using Green

Climacteric Scale, Kollam, Kerala, 2017
Domain Average Score Observe Expecte
Mean(SD) d Range d Range
Psychological-Anxiety 6.67(4.92) 0-18 0-18
Psychological-Depression 4.56(3.51) 0-14 0-15
Physical Symptoms 7.61(4.86) 0-21 0-21
Vasomotor Symptoms 2.74(2.66) 0-6 0-6
Sexual dysfunctional score 1.14(1.01) 0-3 0-3
Total score-GCS 22.39(11.90) 0-52 0-63
4.4. Patterns of health care seeking menopause related symptoms

4.4.1. Health care seeking and preferences of health systems for care.
Health care seeking patterns of the women who had experienced menopause related
symptoms within each domain of the GCS were assessed along with the preferred system
of care (table 4.8). About half of the women who experienced physical symptoms sought
care. The data shows women experienced psychological, vasomotor, sexual symptoms are
less likely to seek care. A majority of the study participants who experienced at least one
symptom preferred to go to modern medicine health care facility. A quarter of those with
symptoms (25%) preferred to seek AYUSH treatment.
Table.4.8. Patterns of health care seeking and preference for type of care
for MRS among women with symptoms, Kollam, Kerala, 2017
GCS Domains Sought care Total N (%)
Psychological 70(19.1) 366(100)
Physical 186(49.7) 374(100)
Vasomotor 33(14.0) 235(100)
Sexual 3(1.6) 192(100)
Health system preference Yes Total N (%)
Modern medicine 247(64.3) 384(100)
AYUSH 96(25.0) 384(100)
Medical Pharmacy 2(0.5) 384(100)
Traditional healers 7(1.8) 384(100)
Two or more of any system of 32(8.3) 384(100)
care
52
4.4.2. Place for health care seeking for menopause related symptoms
Place of health seeking by the women for menopause related symptoms are
described in table 4.9. For psychological symptoms majority of the women went
to public secondary care facility (20%), followed by private clinic (20%) and
public primary level (8.6%) health care facility. Women seem to prefer AYUSH,
private secondary and private clinics to treat their physical symptoms. Most of the
women with vasomotor symptoms went to private secondary, private clinic and
AYUSH.
Table.4.9.Place for health care seeking for menopause related symptoms,

Kollam, Kerala, 2017
Place for Psychological Physical Vasomotor Sexual
health seeking /GCS N=70 N=186 N=33 N=3
domains (100%) (100%) (100%) (100%)
Public primary 13(18.6) 29(15.6) 2(6.1) Nil
Public secondary 14(20) 25(13.4) 4(12.1) 1(33.3)
Public tertiary 3(4.3) 2(1.1) 1(3) Nil
Public speciality- Nil Nil 1(3) Nil

medicine/ neuro
Public speciality- Nil Nil 1(3) Nil
gynaecology
Public speciality- 2(2.9) Nil Nil Nil
Psychology/psychiatry
/ortho
Private clinic 14(20) 30(16.1) 7(21.2) Nil
Private secondary 10(14.3) 35(18.8) 9(27.3) Nil
Private tertiary Nil Nil Nil 1(33.3)
Private speciality- 3(4.3) 2(1.1) 3(9.1) Nil

gynaecology
Private speciality- 1(1.4) 14(7.5) Nil Nil
Psychology/psychiatry
/ortho
AYUSH 9(12.9) 42(22.6) 5(15.2) 1(33.3)
Public primary and private 1(1.4) 2(1.1) Nil Nil

secondary
53
4.4.3. Frequency of care seeking and satisfaction with treatment received
among those who sought treatment for menopause related symptoms
The frequency of care seeking and the self reported satisfaction with care are
tabulated in table 4.10. Among study participants who experienced menopause
related symptoms 60 percent sought treatment about one to three times and 40
percent sought care more than three times in a year. About 60 percent of the
women who sought any care were satisfied with the treatment they underwent.
Table.4.10.Self reported satisfaction to the treatment and among those who

sought treatment for menopause related symptoms
N=200(100)
How many times sought care for symptoms in one year
One-three times 120 (60)
More than three times 80 (40)
Satisfaction with access and treatment to health service

Satisfied 121 (60.5)
Moderately satisfied 69 (34.5)
Not at all satisfied 10 (5)
4.5. Correlates of menopause related symptoms
The correlates for menopause related symptoms were assessed using simple
bivariate analysis. For this analysis, menopause related symptoms have been
categorised into two discrete groups, those with severe symptoms and other with
mild, moderate and no symptoms. Only 4 percent of the participants had never
experienced any symptoms according to GCS score. Chi-square test was done to
explore the possible association between the severities of symptoms experienced
and the specifically identified correlates. . The level of significance for this
statistical analysis was considered as p<0.05(at 5 percent). The results of Chi-
square for association between severity of menopause related symptoms and these
correlates are arranged in Table 4.11.
54
Table 4.11.Distribution of women by menopause related symptoms and
associated factors like nature of menopause, socio-economic characteristics
and socio-economic support, Kollam, Kerala, 2017
Independent Category Menopause related Total N Chi

variable symptoms (100%) square
Not p-value
Severe severe
Nature of Menopause
Menopausal Menopause 57(55.3) 46(44.7) 103(100) 0.062

status Transition
Early post 49(50) 49(50) 98 (100)
menopause
Late post menopause 139(63.5) 80(36.5) 219(100)
Type of Natural menopause 133(55.9) 105(44.1) 238(100) 0.031

menopause Induced menopause 55(69.6) 24(30.4) 79(100)
Age at 40years and less 36 (75.0) 12(25.0) 48(100) 0.016

menopause More than 40 years 152(56.5) 117(43.5) 269(100)
Socioeconomic characteristics and menopause related symptoms

Place of Rural 138(58.2) 99(41.8) 237(100) 0.960
residence urban 107(58.5) 76(41.5) 183(100)
Education Less than high 92(64.8) 50(35.2) 142(100) 0.055

school
High school and 153(55.0) 125(45.0) 278(100)
above
Occupation Do not have 124(57.9) 90(42.10 214(100) 0.869

remuneration
Have remunerated 121(58.7) 85(41.3) 206(100)
work
Marital status Currently Married 164(56.0) 129(44.0) 293(100) 0.136

Currently 81(63.8) 46(36.2) 127(100)
unmarried/widow/
separated/divorced
Caste SC/ST 30(58.8) 21(41.2) 51(100) 0.296

General 94(54.3) 79(45.7) 173(100)
OBC 121(62.4) 73(37.6) 194(100)
Economic Low 84(66.7) 42(33.3) 126(100) 0.023

status
Middle and high 161(54.8) 133(45.2) 294(100)
55
Table 4.11.Distribution of women by menopause related symptoms and
associated factors like nature of menopause, socio-economic characteristics
and socio-economic support, Kollam, Kerala, 2017.Cont’d…
p-value
Severe
Not
severe
Socio economic support and menopause related symptoms
Family Have family 130(52.8) 116(47.2) 246(100) 0.007

support support
Do not have family 115(66.1) 59(33.9) 174(100)
support
Social support Have social support 104(59.1) 72(40.9) 176(100) 0.789

Do not have social 141(57.8) 103(42.2) 244(100)
support
Economic Economically 142(61.2) 90(38.8) 232(100) 0.185

independence independent
Economically 103(54.8) 85(45.2) 188(100)
dependent
Note: (%) are row percentages.
Not applicable/do not know/refused to answer/missing values are removed from analysis.
4.5.1. Menopause related symptoms (MRS) and associated factors (nature of

menopause, socio-economic characteristics and socio-economic support)
A higher proportion of women in the late menopause status were having severe
symptoms when compared to those in menopause transition stage or early
menopause stages. This difference is not statistically significant. Women who had
induced menopause were more likely to have severe symptoms and this
association was statistically significant. Premature menopause increases the
chance of severity of symptoms. The highest level of education attainment was
categorized into two groups for this analysis and the results indicate that women
who had education less than high school report severe symptoms when compared
to those with education level of high school and above. Current occupational
status was categorised as those with remuneration and without remuneration.
However, occupational status does not seem to affect the experience of MRS.
56
Economic status is significantly associated with the severity of the symptoms with
a lower proportion of those with better economic status experiencing severe MRS
when compared to those of lower economic status. A higher proportion of women
who do not have family support report severe symptoms when compared to
women who report having family support.
4.5.2. Menopause related symptoms and other factors (lifestyle, reproductive

history, and other medical history)
In this section the relation between severity of the menopause related symptoms
and self reported life style factors like physical activity, diet, reproductive history
and medical history have been reported in table 4.12.Women with menstrual
irregularity (68.3% vs. 56.6%) and those with one or more pregnancies as
opposed to none (59.2% vs.38.9%) report MRS more frequently. A higher
percentage of participants who had gynecological morbidity had severe MRS. The
participants who reported have high blood pressure, high cholesterol, and other
medical conditions have significantly different severity of MRS when compared
to women who do not have the specific medical condition.
57
Table 4.12. Distribution of women with menopause related symptoms and
lifestyle factors, reproductive health history, other medical history, Kollam,
Kerala, 2017.
p-value
Severe Not severe
Life style factors
Sedentary 25(73.5) 9(26.5) 35(100)
Physical Mild 101(55.2) 82(44.8) 183(100) 0.263
activity Moderate 108(58.7) 76(41.3) 184(100)
Vigorous 11(57.9) 8(42.1) 19(100)
Dietary choice Vegetarian 14(50) 14(50) 28(100) 0.355

Non vegetarian 231(58.9) 161(41.1) 392(100)
Diet control Have control in

fat and sugar in 93(55.0) 76(45.0) 169(100)
diet 0.269
consumption
Do not have 152(60.6) 99(39.4) 251(100)
control in fat
and sugar
Reproductive health history

Previous Had 43(68.3) 20(31.7) 63(100)
menstrual menstrual 0.083
history irregularity
Did not have 202(56.6) 155(43.4) 357(100)
any
irregularity
Number of Never 7(38.9) 11(61.1) 18(100) 0.087
pregnancy One and more 238(59.2) 164(40.8) 402(100)
Number of One 24(57.1) 18(42.9) 42(100) 0.774

Delivery Two and 214(59.4) 146(40.6) 360(100)
more
Normal One 27(54.0) 23(46.0) 50(100) 0.373

Vaginal Two and 173(60.7) 112(39.3) 285(100)
Delivery more
Caesarean One 24(51.1) 23(48.9) 47(100) 0.914

section Two and 29(50.0) 29(50.0) 58(100)
more
Contraceptiv Ever used 128(55.7) 102(44.3) 230(100) 0.094

e history Never used 110(64.0) 62(36.0) 172(100)
58
Table 4.12. Distribution of women with menopause related symptoms and
lifestyle factors, reproductive health history, other medical history, Kollam,
Kerala, 2017.Cont’d…
p-value
Severe Not severe
Complication Yes 23(60.5) 15(39.5) 38(100) 0.862

during No 215(59.1) 149(40.9) 364(100)
delivery
Gynecological Ever had 59(73.8) 21(26.3) 80(100) 0.002

morbidity Never had 186(54.7) 154(45.3) 340(100)
Gynecological Underwent 48(70.6) 20(29.4) 68(100) NA*

surgery Never 10(83.3) 2(16.7) 12(100)
underwent
Other health condition and menopause related symptoms
High blood Yes 105(64.4) 58(35.6) 163(100) 0.044

pressure No 140(54.5) 117(45.5) 257(100)
Diabetes Yes 68(60.7) 44(39.3) 112(100) 0.551

mellitus No 177(57.5) 131(42.5) 308(100)
High Yes 99(67.3) 48(32.7) 147(100) 0.006

Cholesterol No 146(53.5) 127(46.5) 273(100)
Other Yes 46(75.4) 15(24.6) 61(100) 0.003

medical No 199(55.4) 160(44.6) 359(100)
conditions
Waist 124(56.9) 94(43.1) 218(100)

Central circumference 0.530
obesity < 80 cm
Waist 121(59.9) 81(40.1) 202(100)
circumference
>80 cm
Note: (%) are row percentages.
Not applicable/do not know/refused to answer/missing values are removed from analysis
* One cell value less than5
.
59
4.6. Health care seeking for menopause related symptoms and
associated factors
Pattern of health care seeking by the women who experienced menopause related
symptoms has been examined by categorising care seeking into those who sought
care at least once sought care for any symptoms and those who never sought care
for any symptoms. This enabled the identification of key factors associated with
health care seeking for MRS.
4.6.1 Health care seeking for menopause related symptoms and nature of
menopause, socio-economic factors
Health care seeking for MRS tabulated by specific socioeconomic factors and
socioeconomic support are presented in table 4.13. Care seeking for MRS was
not associated with any of these factors.
Table.4.13.Health care seeking for MRS by nature of menopause, type of

menopause and socio-economic characteristics, Kollam, Kerala, 2017
Independe Category Health seeking for any Total N Chi square
nt variable of the MRS (100%) p-value
Sought Never
care at sought care
least once
Nature of Menopause
Menopausal Menopause transition 44(43.1) 58(56.9) 102(100)

status Early post menopause 50(54.3) 42(45.7) 92(100) 0.140
Late post menopause 114(54.5) 95(45.5) 209(100)
Type of Natural menopause 117(51.8) 109(48.2) 226(100) 0.101

menopause Induced menopause 47(62.7) 28(37.3) 75(100)
Socioeconomic characteristics and health seeking

Place of Rural 114(49.8) 115(50.2) 229(100) 0.399
Residence Urban 94(51.0) 80(46.0) 174(100)
Less than high school 74(54.8) 61(45.2) 135(100) 0.361

Education High school and above 134(50.0) 134(50.0) 268(100)
60
Table.4.13.Health care seeking for MRS by nature of menopause, type of
menopause and socio-economic characteristics, Kollam, Kerala, 2017.Cont’d…
Independe Category Health seeking for any Total N Chi square
nt variable of the MRS (100%) p-value
Sought Never
care at sought care
least once
Occupation Do not have 105(51.5) 99(48.5) 204(100) 0.954

remuneration
Have remunerated 103(51.8) 96(48.2) 199(100)
work
Marital Currently Married 142(50.5) 139(49.5) 281(100) 0.511
status Currently
unmarried/widow/ 66(54.1) 56(45.9) 122(100)
separated/divorced
Caste SC/ST 20(39.2) 31(60.8) 51(100) 0.158
General 86(52.1) 79(47.9) 165(100)
OBC 101(54.3) 85(47.9) 186(100)
Economic Low 59 (47.6) 65(52.4) 124(100) 0.280

status Medium and above 149(53.4) 130(46.6) 279(100)
Socio economic support and health care seeking

Family Have family support 121(51.5) 114(48.5) 235(100) 0.953
support Do not have family 87(51.8) 81(48.2) 168(100)
support
Social Have social support 86(50.9) 83(49.1) 169(100) 0.804

support Do not have social 122(52.1) 112(47.9) 234(100)
support
Economic Economically 122(54.5) 102(45.5) 224(100) 0.200

independenc independent
e
Economically 86(48.0) 93(52.0) 179(100)
dependent
4.6.2. Health care seeking for menopause related symptoms and lifestyle
factors, reproductive health history, other medical conditions
Health care seeking for MRS was tabulated by lifestyle related factors,
reproductive health history and other medical conditions (table 4.14) Participants
who experienced any menstrual irregularity or reported some gynecological
61
morbidity were more likely to seek health care MRS when compared to women
who did not. Women who reported Diabetes Mellitus (DM) and other medical
conditions were also more likely to seek health care for MRS, even though
women who have DM do not report severity of MRS in anyway different from
those who do not report having DM. Care seeking for MRS amongst those who
did not have any other additional morbidities was examined (not shown in table).
There was not variation in care sought for MRS amongst those who had additional
morbidities when compared to those who did not (54.4% vs. 46.5%).
Table 4.14.Health care seeking for MRS by lifestyle factors, reproductive

health history, other medical conditions, Kollam, Kerala, 2017
Independent Category Health seeking for any of Total N Chi
variable the MRS (100%) square
p-
Sought Never value
care at sought care
least once
Reproductive health history and health care seeking for menopause related
symptoms
Previous Ever had 38(63.3) 22(36.7) 60(100) 0.049

menstrual Never had 170(49.6) 173(50.4) 43(100)
irregularity
Number of Never 10(58.8) 7(41.2) 17(100) 0.543

pregnancy One and 198(51.3) 188(48.7) 386(100)
more
Number of One 19(45.2) 23(54.8) 42(100) 0.405

Delivery Two and 179(52.0) 165(48.0) 344(100)
more
Complication Yes 17(47.2) 19(52.8) 36(100) 0.608

during No 181(51.3) 169(48.3) 350(100)
delivery
Presence of Yes 50(65.8) 26(34.2) 76(100) 0.006

any No 158(48.3) 169(51.7) 327(100)
gynecological
morbidity
Gynecological Underwent 41(64.1) 23(35.9) 64 (100) 0.464

surgery Never had 9(75.0) 3(25.0) 12(100)
62
Table 4.14.Health care seeking for MRS by lifestyle factors, reproductive health
history, other medical conditions, Kollam, Kerala, 2017.Cont’d…
Independent Category Health seeking for any of Total N Chi
variable the MRS (100%) square
Sought Never sought p-value
care at care
least once
Other medical history and health seeking for MRS
High blood Yes 84(52.8) 75(47.2) 159(100) 0.693
pressure No 124(50.8) 120(49.2) 244(100)
Diabetes Yes 65(60.7) 42(39.3) 107(100)

mellitus No 143(48.3) 153(51.7) 296(100) 0.027
High Yes 82(56.6) 63(43.4) 145(100)

Cholesterol No 126(48.8)) 132(51.2) 258(100) 0.137
Other medical Yes 39(65.0) 21(35.0) 60(100) 0.025

conditions No 169(49.3) 174(50.7) 343(100)
4.7. Multivariate regression model to explore the factors associated with

MRS.
The variables identified through the bivariate analysis were used to examine the
strength of association using for multivariate logistic regression model to assess
the while controlling for other variables. The variables considered were family
support, social support and economic independence. Lack of family support was
found to be associated with severity of menopause related symptoms.
Table.4.15. MRS Severity and predictors

Predictor variables(reference Adjusted Odds 95% CI
category) Ratio(OR)
Family support(no) 1.789 1.182-2.697
Social Support(no) 0.844 0.561-1.268
Economic independence(no) 0.234 00.531-1.168
63
CHAPTER 5
DISCUSSION
5.1. Summary of key findings
This chapter discusses the key results of the study, which aimed to assess the
magnitude of menopause related symptoms, health seeking behaviour and
associated factors among women aged 35-60 years who were in menopause
transition or in the post menopausal phase. The study mainly looked into the
extent of menopause related symptoms and factors related to the experience of
these symptoms among women in Kollam district. Since there is cross-cultural
variation in menopause related symptoms(Kumar Mishra, 2011), the results of the
current study results have been compared to other studies conducted in India.
The participants were randomly selected from the rural and urban communities
with proportional allocation to rural and urban population in Kollam District
(Census, 2011b). Ages of the participants ranged from 35-60 years and 44.8%
participants belong to age group 55 or more. The currently available census data
on age distribution of the female population in Kollam district in four categories
was 44percent below 45 years of age, 20.5percent of 45-49 years of age, and
16.4percent as 50-54 years of age and 19.2percent belonging to the above 55
years of age category(Census, 2011a). But the sample in the current study has an
age distribution that did not exactly match that from the Census of 2011 with
44.8% are in age group more than 55 and above, 24.3 percent are in between 50-
54 years old, 20.5 percent are in 45-49 years and only 10.5 percent are in age
group less than 45 years old. The disparity in distribution of women in different
64
age group can be explained by three reasons. One is that the average age at
menopause in the current study was 46.11 years, so the women who are in or
around the menopause were only included in the study. Second is the inclusion of
the women in the study based on menopausal status. The study participants were
selected using a screening questionnaire and this excluded women who were not
in menopausal transition or in the post menopausal phase. A third reason could be
because of women in the working age group (less than 55 years) were not
available and therefore excluded from the study (due to replacement for closed
houses during the sample selection process).
There were 103 women in menopausal transition, 86 women in early post
menopausal stage and 219 women are in late post menopausal stage. Among 317
women who attained menopause, 79(24.9%) had an induced menopause and for
68(21.45%) of them it was surgically induced. Early age at menopause or
premature menopause is associated with the prevalence of menopause related
morbidity(Grigoriou et al., 2013).
Out of 317 post menopausal women 48(15.14%) were in the premature
menopause stage, that is menopause occurred when they were less than 40 years
among all women who were aged 35 to 60 years of age and included in the study.
When the percentage of women who experienced premature menopause was
assessed among those aged 35-49, it was 11.9 percent. The estimate of those who
experienced premature menopause in the present study is higher than that
estimated for Kerala (3.7%) but comparable with states like Gujarat (10.7%) and
Karnataka (10.6%) (estimated the proportion of premature menopause in 30-49
65
years old women) in non Empowered Action Group (non EAG) States using the
National Family Health Survey-2 data of 1997-98 (Syamala and Sivakami, 2005).
Nearly half of the women had highest level of their education as high school. Half
of the women did not undertake remunerated work. Majority of the women were
currently married and most of the others were widows. A higher proportion of the
women belonged to medium economic index compared to low and high economic
index. More than half of the participants had family support and economic
independence; but most women do not seem to have social support. A majority of
the study participants were older and educated. This study examined family
support, economic independence and social support as part of the process of
empowerment and assessed associations with menopause related symptoms and
health seeking behaviour.
More than half of the participants had two pregnancies and two deliveries. There
were 4.3 percent women who never had a pregnancy. Around one fourth of the
participants underwent caesarean section. Among 420, eighty women had history
of gynecological morbidity, 68 participants underwent gynecological surgery and
six of the participants had a history of gynecological cancer. According to
population based cancer registry, commonly occurring gynecological cancer
prevalence among 35-60 years old women is 0.22 percent in Kollam(Sebastian et
al., 2008). The current study shows 1.42 percent participant as affected by most
common gynecological cancer like CA breast (3 cases), CA ovary (2 cases) and
CA cervix (1 case).So in the current study cancer prevalence seems to be higher
than that reported (p<0.0001).
66
High blood pressure was reported by 163 participants, Type 2 Diabetes Mellitus
was reported by 112 participants, high cholesterol was reported by 147
participants and other known medical conditions was reported by 61 participants.
Waist circumference was measured and central obesity was present in 46.4
percent of the participants. Since there is a sizable proportion of the population
who underwent hysterectomy and attained menopause prematurely, there is a
likelihood of long exposure to menopause and menopause related symptoms.
Average age at menopause among post menopausal women in the current study
was 46.1 years and average age at natural menopause was 47.4 years. The
estimated mean age at menopause in the current study is less than that estimated
in two other studies from Kerala which were conducted in Idukki and Kannur, but
among a relatively smaller sample. The present mean age at menopause of 46.1
years is higher than that obtained from a Pan Indian Study, which estimated the
age at menopause of Indian woman as 45.6 years and age at natural menopause as
46.2 years(Ahuja, 2016).
Recent literature in India on estimates of age at menopause ranges from 44.54
years to 49.95 years. The average age at menopause in different studies has been
listed in Table 5.1.
67
Table5.1.Mean age at menopause in different studies in India
Studies Region Sample Age group of Mean age
size* study at natural
participant menopause
(in years)
Present study Rural and 317 35-60 47.41
Urban Kollam,
Kerala
(Subrahmanyam and Rural Idukki, 120 40-55 47.95
Padmaja, 2016) Kerala
(Borker et al.,2013) Rural Kannur, 106 40-80 48.26
Kerala
(Monika Urban Odisha 100 >40 44.82

Satpathy.,2014)
(Kulkarni et al., Urban Mysore, 100 40-65 46.70
2016) Karnataka
(Singh and Pradhan, Rural New Delhi 252 40-54 46.24

2014)
(Kakkar et al., 2007) Urban Punjab 208 35-65 48.70
(Randhawa and Rural Amritsar, 100 40-60 49.95

Sidhu, 2014) Punjab
(Sharma et al., Urban Jammu 117 >40 47.35

2007a)
(Bairy et al., 2009) Coastal 352 >40 48.67
Karnataka,
Udupi
(Ahsan et al., 2015) Patna, Bihar 95 40-65 45.29

(Mahajan et al., Shimla, 100 35-65 44.54
2012) Himachal
Pradesh
(Garg et al.,2015) Agra,Uttar 286 40-55 48.26

Pradesh
*women who attained menopause only considered for analysis for average age at natural menopause.
A significantly high proportion (95.95%) of women had any one of menopause
related symptoms. The percent of the women suffering from any of the
menopausal symptoms such as psychological, physical, vasomotor and sexual
dysfunction were 86.9%, 89.3%, 56% and 65.6% respectively; as assessed by
Green Climacteric Scale across the four domains. Psychological symptoms were
68
comparatively more severe in the late post menopausal stage. Physical symptoms
and vasomotor symptoms have equal severity among all menopausal stages and
did not vary significantly. Sexual dysfunction is comparatively high in late post
menopausal stage and less severe in menopausal transition stage.
Psychological Symptoms: The common severe psychological symptoms were
psychological anxiety with sub domains of heart beating quickly or strongly
(61.1%) and difficulties in sleeping (55.95%).The psychological symptom which
was the most frequent was feeling tired or lacking energy (68.09%) and it was
severe for 48.3 percent of the women and the most common mild psychological
symptom was crying spells (65.4%) and it was present in 37.1 percent of women.
Physical symptoms were assessed using a seven symptom scale and the most
frequently reported physical symptom was muscle and joint pain (73.3%) and 62
percent of women have severe muscle and joint pain. Vasomotor symptoms were
hot flushes and night sweats. Hot flush was present in 54.5 percent of the women
and it was severe for 62 percent of those with such symptoms. Night sweats were
present in 55.2 percent of the women and it was severe in 61.2 percent of them.
Among 294 participants in the study, with menopause related symptoms, 193
(65.64%) reported sexual dysfunction.
Reports of menopause related symptoms vary across different studies. The current
study has low prevalence reported than a similar study in Idukki with Green
Climacteric scale using 120 participants. The study findings were muscle and joint
pain 95%(p<0.0001),parts of the body feeling numb or tingling
93.3%(p<0.0001), difficulty in sleeping 86.5% (p<0.0001), irritability
85.8%(p<0.0001) and these rates were significantly higher than those reported in
69
the current study, but the prevalence of muscle and joint pain (p<0.14) were
similar to the study findings from Agra(Garg et al., 2015).Vasomotor symptoms
like hot flushes 46.7%(p< 0.0013) and night sweats 50%(p<0.032) reported from
the study based in Idukki were lower than that reported in the current study. The
mean score of previous Kerala study and current study in psychological anxiety
subscale (6.49 vs. 6.67), depression subscale (4.83 vs. 4.56) physical scale (6.54
vs. 7.61) and sexual dysfunction scale (1.28 vs. 1.14) are comparable. But the
mean score of vasomotor scale was 1.28 in the previous study and 2.74 in current
study is different.(Subrahmanyam and Padmaja, 2016) Hot flushes and sweats
(53.9%) were reported in a study from urban Jammu (Sharma et al., 2007)
wherein the rates are similar(0.573) to the present study findings.
The study findings concur with Global and Asian study findings regarding more
prevailing symptom as physical than vasomotor symptoms(Avis et al., 2001;
Haines et al., 2005).
5.2. Menopause related symptoms and its correlates
Women in late menopause, who had induced menopause and premature
menopause were affected by severe symptoms. There was a significant positive
correlation between postmenopausal symptoms and age. The number of
symptoms and severity increased with age. (Kulkarni et al., 2016; Mahajan et al.,
2012) . These findings from earlier studies underpin the current study results that
women in the late menopause status are more vulnerable to experiencing severity
of menopause related symptoms.
70
While considering the place of residence there were no differences in reporting of
menopause related symptoms among rural and urban residents. The lowest
inequality in rural-urban divide in terms of public health status may be the
rationale behind it in Kerala(Kumar and Devi, 2010). Women in low economic
status, have no family support are reported to have more severe symptoms. The
participants who reported to have ever been diagnosed gynecological morbidity,
high blood pressure, high cholesterol, and other medical conditions are more
likely to have severe symptoms. Menopause related symptoms are significantly
related to sociodemographic characteristics, life style, and other health problems
and these factors have a direct and modifiable effect on prevalence of menopause
related symptoms.(Li et al., 2003; Ishizuka et al., 2008). The factors contributing
severity of menopause related symptoms are low income, low educational status,
divorce, higher parity, high BMI, and presence of chronic diseases.(Li et al.,
2012). The present study findings about correlates of menopause related symptom
severity are in correspondence with existing knowledge in terms of low economic
status, less family support, and presence of chronic diseases. The other correlates
like menstrual and reproductive history were also related to menopause related
symptoms and this matches findings from a study of ‗Particularly Vulnerable
Tribal Group‘ from West Bengal(Dasgupta et al., 2015). Multivariate analysis
indicated that family support is a significant correlate of severity of menopause
related symptoms after controlling for other factors. The women who had family
support tend to report less severe symptoms. It was already established that the
family support in terms of affective support or involvement of the partner, a good
communication in the family is associated with less severity of menopausal
71
symptoms. In other words lack of family support in the middle ages can be a
predictor of severity of menopause related symptoms(Huerta et al., 1994).
5.3. Correlates of health care seeking patterns for menopause

related symptoms
Health care seeking preference and practice for menopause related symptoms
were assessed. Out of 366 participants who had menopause related symptoms 200
women (54.64%) sought care. Among the women who sought care at least once,
19.1 percent sought care for psychological symptoms, 49.7% went for physical
symptoms, 33 % for vasomotor symptoms. Psychological symptom were present
in 366 women, 70 of them sought care; majority of the women went to public
secondary (20%), private Clinic (20%) and public primary (18.6%) health centre.
physical symptoms were present in 374 participants and 186 women sought care,
majority of them went to AYUSH (22.6%), private secondary (18.8%),public
primary(15.6%) and public secondary(13.4%).Vasomotor symptoms were present
in 235participants, only 33 women sought care mainly in private secondary
(27.3%) and private clinics(21.2%).For sexual dysfunction only 3 women sought
care. Among the women who sought care 60 percent of them sought care one to
three times and 40 % of them sought care more than three times in a year.
The proportions of women sought care for any one of the menopause related
symptoms can be comparable to a population based study in United States, were
60 percent of the participants sought care(Williams et al., 2007) and it is different
from population studied in Malaysia in which three by fourth of the study
participants did not seek care for any menopause related symptoms.(Bahiyah
Abdullah et al., 2017). The current study participants prefer to seek health care
from modern health care facility rather than AYUSH or directly from pharmacy.
72
One study from Nepal found that the majority of the women sought care directly
from pharmacy and most of them were ignorant about health care seeking for
menopause related symptoms(Gyawali S et al., 2016). In the current study, around
one third of the women who sought care were not satisfied with the access and
treatment that they received. A study in Aligarh, India found that most of the rural
women had no access to the treatment when compared to those living in urban
area(Khan et al., 2016).
Majority of the women sought care for physical symptoms mostly muscle and
joint aches. The suffering of the women from physical symptoms like muscle and
joint pain may have been interpreted as a part of the aging process or any medical
condition or any other pathology rather than a consequence of menopausal status.
The factors associated with health care seeking for menopause related symptoms
were history of previous menstrual irregularity, presence of gynecological
morbidity; Type 2 Diabetes mellitus and other medical conditions in the current
study.
The health care seeking behaviour of women with any menopause related
symptoms were influenced by age, frequency and severity of symptoms in
Europe(Constantine et al., 2016). The pattern of health seeking was not associated
with race, age group, parity, marital status and occupational status(Bahiyah
Abdullah et al., 2017). The current study could not find any association of
sociodemographic factors with health seeking behaviour for menopause related
symptoms. The health care seeking behaviour of the current study participants
were not specific for menopause related symptoms, most of them sought care for
physical symptoms that is easy to address because it can be related to either some
73
known pathology or as a process of aging. The lack of knowledge regarding
menopause related symptoms like psychological depression, anxiety, vasomotor
symptoms and sexual dysfunction persist even in a state like Kerala which has
achieved high human development index and gender related development
index(CDS, 2005).
5.4. Limitations of the study
The Questionnaire used in the study contained 8 sections. Section F –Knowledge
attitude perception questionnaire could not find any objective data because it was
highly correlated with the part of the questionnaire. It was already loaded by the
influence of other questions. The study could not address the actual factors
associated with severity of menopause related symptoms because the factors are
highly correlated with each other, so further effort for multivariate analysis to
identify the independent factors and effects was not carried out. Inclusion of
qualitative research methods could have been a better option to explore the factors
associated with menopause related symptoms and health care seeking in this
context in terms of bio-cultural perspective. The role of recall bias in self
reporting of the symptoms and morbidity could have affected the objective
measurement and it was one of the limitations in the study.
5.5. Strengths of the study
The community based cross sectional study and primary data were collected
allowing for rural and urban representation. The ward clusters were randomly
selected from the list of Panchayats, Muncipality and Corporation in Kollam
District. The chance of inter- observer variability reduced, since it was a single
investigator study. The Green climacteric scale (used for assessing the outcome
74
variable) was validated in these study settings. Reliability of waist circumference
measurement (WC) made sure by using standardized protocol and instrument.
5.6. Conclusions
Menopause related symptoms are highly prevalent among middle aged women in
Kollam district. Physical symptoms are the most commonly reported ones. The
prevalence of psychological anxiety, depression, hot flushes, night sweats and
sexual dysfunction are not negligible. The factors associated with severity of
menopause related symptoms are type of menopause, age at menopause,
education, economic status and family support. Family support tends to mitigate
against severe symptoms. The study participants sought care mainly for physical
symptoms rather than any other menopause related symptoms. They did not seek
care for sexual dysfunction even though many women reported these symptoms.
Health seeking behaviour was not associated with nature of menopause or any of
the socio-demographic or economic factors; but it was associated with history of
previous menstrual history, gynecological morbidity, type 2 Diabetes Mellitus and
other medical conditions. This indicates a lack of knowledge regarding treatable
menopause related symptoms. Further studies are needed to ascertain whether the
high levels of hysterectomy observed in this study are wide spread. It is need for
public health system in the State to address the issues of middle aged women as
the State has achieved desirable maternal and child health indicators.
5.7. Policy Implications
1. The health care needs of the middle aged women are influenced by bio-
cultural determinants (age at menopause, gender roles, social construction).
75
Investment should be made for research focusing on these aspects, which
should inform policy.
2. Health promotion activities at the community level need to be tailored to
address the multiple health needs of middle-aged perimenopausal and post
menopausal women. Special focus on lifestyle modifications in this window
of opportunity will help also in preventing chronic diseases.
3. As a part of comprehensive health care, the Family Wellness Centre being
newly established in Kerala should have Well Women Clinics which include
services for both physical and mental health conditions experienced by
middle aged women. The existing health programmes for life cycle approach
to women The Reproductive, Maternal, Newborn, Child, and Adolescent
Health programme (RMNCH+A) and National Program for Prevention and
Control of Cancer, Diabetes, CVD and stroke(NCPDCS) can have better
links in addressing the health crisis of middle aged women.
4. Since prevalence of common gynecological conditions is high, this signifies
the urgent need for community based screening for such condition especially
for cancers.
5. Health providers need to be sensitized to special health needs of middle aged
women, both physical and mental health needs related to menopause.
76
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ANNEXURE I
FLOW CHART OF LITERATURE SEARCH PROCESS
Identification
Pub med and Google Scholar Additional records identified

data base search (1996-2016) after expert recommendation and
with key words cross referencing
(n=
(n = )
Records that are repeating or duplicating

removed
Screening
Records screened for

relevance and full text Non relevant studies
access (genetic/molecular)
studies excluded
(n = )
Eligibility
Full-text articles Full-text articles

assessed for eligibility excluded, with no
(n = 109) availability (n=23
9) ) reasons
(n = )
Included
Key Studies included in

the review (n=86)
I
ANNEXURE II
NAME AND IDENTIFICATION NUMBER OF CLUSTERS IN THE

STUDY
A. Rural Clustering Criteria

Rural clusters –3 selected block division-9 Grama Panchayat clusters -18
wards-13-14 participants (total of 240 participants).
A.1.Name and Numbering of Rural Clusters

1. Chittumula Block -Mandrothuruthu –ward number 7-B01/G01/W01
2. Chittumula Block-Mandrothuruth-ward number11- B01/G01/W02
3. Chittumala Block-Penayam-ward number2-B01/G02/W01
4. Chittumuala Block-Penayam –ward number 14-B01/G02/W02
5. Chittumala Block-Trikkadavoor_ward Number 4-B01/G03/W01
6. Chittumala Block-Trikkadavoor-ward number 10-B01/G03/W02
7. Oachira Block-Kulasekarapuram-ward number18-B02/G01/W01
8. Oachira Block-Kulasekarapuram-ward number21-B02/G01/W02
9. Oachira Block-Oachira-ward number3-B02/G02/W01
10. Oachira Block-Oachira-ward number 9-B02/G02/W02
11. Oachira Block-Thodiyoor-ward Number 9-B02/G03/W01
12. Oachira Block-Thodiyoor-ward number 17-B02/G03/W02
13. Kottarakara Block-Veliyam-wardnumber1-B03/G01/W01
14. Kottarakara Block-Veliyam-ward number3-B03/G01/W02
15. Kottarakara Block-Ezhukone-ward number13-B03/G02/W01
16. Kottarakara Block-Ezhukone-ward number 16-B03/G02/W02
17. Kottarakara Block-Poyappally-ward number 7-B03/G03/W01
18. Kottarakara Block-Pooyapally-ward number 10-B03/G03/W02
II
B.Urban Clustering Criteria
Muncipality-3mucipality clusters -3 wards from each=10-11 participants
Corporation clusters=9 wards=10participants
B.1.Name and Numbering of Urban Clusters- Muncipality
1. Muncipality-Karunagappally-Manpozhil-M01/W01
2. Muncipality-Karunagappally-Kanneti-M01/W02
3. Municipality-karunagappally-Pakal veedu-M01/W03
4. Muncipality-Punalur-Arampunna-M02/W01
5. Muncipality-Punalur-Kakkode-M02/W02
6. Muncipality-Punalur-Paravattom-M02/W03
7. Muncipality-Pravoor-Attinpuram-M03/W01
8. Muncipality-Paravoor-Kurandikkulam-M03/W02
9. Muncipality-Paravoor-Karamandal-M03/W03
B.2.Name and Numbering of Urban Clusters-Corporation

1. Kollam Corporation-Maruthadi-C1/W01
2. Kollam Corporation-Neeravil-C1/W02
3. Kollam Corporation-Uliyakovil-C1/W03
4. Kollam Corporation-Kavanadu-C1/W04
5. Kollam Corporation-Mathili-C1/W05
6. Kollam Corporation-Asramam-C1/W06
7. Kollam Corporation-Bharanikkav-C1/W07
8. Kollam Corporation-Tangassery-C1/W08
9. Kollam Corporation-Thirumullavaram-C1/W09
Total Number of Clusters in Rural area-18

Total Number of Clusters in Urban area-18
Total Number of clusters-36
III
ANNEXURE III
FLOW CHART-PARTICIPANTS RECRUITMENT
Total house hold

visited(n=714)
218 participants were not

eligible for the study
430eligible participants
included
6 participants data
4 patricipant didnot
excluded because of
given consent
unclear data
420 eligible
paticipant's data
included for final
analysis.
IV
ANNEXURE IV
CLUSTERWISE REPORT ON RESPONSE OF STUDY PARTICIPANTS
Serial Cluster ID Area Number Number Number
Number of who to be
women give included
in the consent in the
inclusion study
criteria
1 C1/W01 Urban 10 10 10
2 C1/W09 Urban 10 10 10
3 C1/W04 Urban 10 10 10
4 M01/WO2 Urban 10 10 10-11
5 B01/G01/W01 Rural 14 14 13-14
6 B02/G01/W01 Rural 13 13 13-14
7 B2/G01/W02 Rural 13 13 13-14
8 B2/G03/W01 Rural 14 14 13-14
9 B02/G03/W02 Rural 13 13 13-14
10 B01/G03/W01 Rural 13 13 13-14
11 B01/G03/W02 Rural 15 15 13-14
12 C01/W06 Urban 10 9 10
13 C1/W03 Urban 10 10 10
14 B02/G02/W01 Rural 13 13 13-14
15 B02/G02/W02 Rural 13 13 13-14
16 M01/WO1 Urban 10 10 10-11
17 M01/W03 Urban 10 10 10-11
18 C01/W05 Urban 10 10 10
19 C01/W02 Urban 10 10 10
20 C01/W07 Urban 10 9 10
21 C01/W08 Urban 10 10 10
22 B03/G03/W01 Rural 14 14 13-14
23 B01/G03/W02 Rural 13 12 13-14
24 B03/G02/W01 Rural 13 13 13-14
25 B03/G02/W02 Rural 14 14 13-14
26 B01/G02/W01 Rural 13 13 13-14
27 B01/G02/W02 Rural 14 14 13-14
28 B03/G01/W01 Rural 13 13 13-14
29 B03/G01/W02 Rural 14 14 13-14
30 M03/W01 Urban 11 11 10-11
31 M03/W02 Urban 11 11 10-11
32 M03/W03 Urban 11 11 10-11
33 M02/W01 Urban 12 11 10-11
34 M02/W02 Urban 12 11 10-11
35 M02/W03 Urban 12 12 10-11
36 B01/G01/W02 Rural 12 12 13-14
Total number of clusters-36 430 426
V
ANNEXURE V
DISTRIBUTION OF AVERAGE AGE AT MENOPAUSE AND AVERAGE AGE
AT NATURAL MENOPAUSE
VI
ANNEXURE VI
AchuthaMenon Centre for Health Science Studies (AMCHSS)
Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST)
Trivandrum-11
INFORMED CONSENT - Participant Information Sheet.
Survey Location Date of Survey Name Of
number Rural D D M M Y Y Y Y Corporation/Municipality/CD block
Urban Name of Panchayat &Ward
Namaskaram, I am Sajitha.S, Student of Master of Public Health in Achuta Menon Centre for
Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology,
Thiruvananthapuram. I am conducting a study on ‘Menopause Related Symptoms and their
correlates in Kollam District, Kerala.’ My study participants are women aged 35 to 60 years. I
came here as a part of my study to collect information regarding the specific health related issues
of women in middle ages.
The purpose of my study is to find out the extent of menopause related symptoms, to describe the
personal and sociodemographic factors associated with menopause and to the characteristics of
health seeking behaviour and its associated factors in women in menopausal transition and post
menopause period in the community. The importance of my study is that, majority of women not
reporting their reproductive health related issues in midlife which affects the daily quality of life of
the women, and is a window period need individualized attention to prevent development of
chronic disease in later ages.
If you are willing to participate it will take 15-25 minutes, you will be asked few questions on your
social, economic characteristics, reproductive related details, medical conditions if any,
knowledge and perception regarding menopause, menopause related symptoms, and health care
seeking behaviour. I will measure waist circumference which is variable in my study. I will make
sure your convenience and privacy while interview and assuring it will not harm you any way.
Your participation in the study will not give any direct benefit to you now, but it may help to
influence the policy makers or programme planners while making new health policy for women or
review of existing programmes for middle aged women.
The information that researcher collected will be kept confidential and safe with the researcher.
The participation in the study is completely voluntary, and at any point of time you can withdraw
from study. It will not harm you anyway. If you have any doubts regarding the research you can
contact me (my number is 8111818098).If you want any clarification, regarding the study you can
contact the Member Secretary of Institutional Ethics Committee (IEC), Dr. Mala Ramanathan of
SCTIMST. The Member Secretary can be contacted as 0471 2524234.
Thank You,
Signature of the Researcher:

Sajitha.S, MPH 2016 Batch, AMCHSS, SCTIMST, Trivandrum- 11
VII
INFORMED CONSENT-Participant Consent Form
Survey Date of Survey Name Of

number Location D D M M Y Y Y Y Corporation/Municipality/CD
Rural block
Urban Name of Panchayat & Ward
1.I have read about this study in the information form and I have clarified all the doubts
that I had.
2. I also understand that my participation in the study is voluntary and that I can, at any
time, discontinue my participation in the study.
3. I understand that my identity won’t be revealed in any published or released information
from this study.
4. I am voluntarily agreeing to be a part of this study.
Signature part of Consent Form
 Signature/ Thumb impression of Participant:
 Name of the Participant: ____________________________

IN CASE OF VERBAL CONSENT
 Signature of Witness:
 Relation To the participant:
_____________________________
 Name of the Witness:
_____________________________
 Signature of interviewer:
 Date and Time: _________/___________/______________
VIII
ANNEXURE VII
AchuthaMenon Centre for Health Science Studies (AMCHSS)

Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST)
Trivandrum-11
Interview Schedule
Survey number Location Date of Survey Name of Corporation/

Rural D D M M Y Y Y Y Municipality/CD block
Name of Panchayat/Ward
Urban Number
SECTION A. Checklist before proceeding
Hous Number of NO. Name of the Age(Com Currently Willingness to

e women aged Woman pleted Pregnant/ participate
Num 40-60 years age by Delivered in last
ber old June six months/
2017) history of abortion
in last three
months
COD A* B* C* D* E* F*
E
1 Yes No Yes No
If more than one 2 Yes No Yes No

women present in
the household, list 3 Yes No Yes No
who all are present
and enquire 4 Yes No Yes No
information, then 5 Yes No Yes No
select by KISH
method.
(Note: A*-Women with eligible age group in the household. B*-Number of women from
eligible age group in household, who were present at the time of survey. C*-Name of the
woman who are present in the time of survey. D*-the completed years of women by
2017.E*-Using for inclusion or exclusion criteria. F*-asked for willingness to participate.)
IX
SECTION B: Screening Questionnaire for Ascertainment of Menopausal stages
Sl Question Response An Instructions

no. swe
r
i Name of the Respondent
ii Address
iii Cluster ID /UID
iv Age of the respondent(in completed
years)
I am going to ask a few questions about If Yes, can Quit
your menstrual periods. the study after
1. Have you had your periods during the past 1.Yes explanation. If
two months? 2.No No, proceed to
Qes.2
2. For those who answer No, check: Just to 1.Yes, I have not If Yes, can
make sure I am verifying, you have not had my periods proceed to
had your periods during the past two during the past two Qes.3.If No can
months quit the study.
months
2. No, I have had
periods during the
past two months.
3. Why do you think you have not had your 1. I usually have If the answer is
periods during the past two months? my periods once in 1, can quit the
two or more study. If the
months. answer is 2,
2.I have been proceed to the
having irregular Qes 5.If the
periods for a while answer is 3
now proceed to Qes
3.Can’t say: 4.
4. Are you having amenorrhea since last 6 1.Yes If yes,

months to 12 months.(reference period; confirmation of
the date of study) can be by 2.No Menopause (the
natural/induced(surgical/chemotherapy/ra current period is
diation) post menopause)
5. Can you tell me how was your menstrual 1.Regular If the answer is
cycle last 3 years.(Current history of Irregular, go to
menstrual cycle in last one to three years, 2.Irregular Qes. no 6,If it is
since 2014) Regular Quit
the interview.
6. Which type of irregularity( Any 1.Amenorrhea for If either one
variability in duration and flow of any one more than 60 days option is present
menstrual cycle in the absence of any 2. Persistent the women can
known pathology )do you have difference of 7 days fall in
now?(reference period the date of study to or more in length of menopausal
2014 corresponding month –probably consecutive cycles transition
June-August 2014) (recurrence within criteria. Can be
10 cycles) eligible
X
participant for
the study.
Note: Eligible for the study : (Yes/No)
SECTION C - Socio demographic data
Ser Question Response (Mark Instructions

ial correspo
No nding to
. the
answer)
1 Unique Identification
Number;
2 Date
3 Time
4 Did you ever attend 1.Yes If yes, go
school? 2.No qes.5.If no go
to qes.6
5 Up to what level have 1 .Primary.
you studied? 2. High school.
3.Higher secondary and
above
4.Professional education
6 Are you currently 1.Yes If Yes go to
earning a financial 2.No Qes.7.If No go
remuneration? to qes.8.
7. What is the nature of 1.Daily wages
your work? (eg.MNREGA)
2. Self employment.
3. Salaried employment.
4.others(specify)
8. What is your current 1.Married
marital status 2.Not married
3.Widowed
4.Separated
5.Divorced
99. No response/Refuse to
respond.
9 In this household who 1.Spouse
all are living with 2.Children only(<=14 years)
you? 3.Older children(>14 years)
(can elicit multiple 4.Adult female relatives
answer) 5.Adult male relatives
6.Living alone
7.others(specify)
10. What is your current 1. Income from current
XI
means of household employment.
livelihood? 2. Income from previous
(multiple answers can employment & other
be possible)
welfare Govt. fund
3. Spouse income.
4. Children’s income.
5.Supported by relatives
6.Others(specify)
11. What is the nature of 1.Owned
ownership of the 2.Rented
house you currently 3.Relatives’ house
live in?
4.Others(specify)
99. Don’t know/No
response/Refuse to respond
12. What type of house do 1. House with roof Either one of
you have? tiled/sheet/leaf and floor the option can
(Observed information which is not finely be selected. If
also can be used) the particulars
cemented(unpolished floor)
in the options
2.House with concrete roof fall together,
but floor is only then specify.
cemented/red oxide
3. House with paved tiles in
the courtyard and concrete
roof with tiled floor with
designed landscape.
4.others(specify)
13. Which of these 1.Mixer Grinder

Electrical appliances 2.Refrigerator
do you own?(Multiple
3.Washing machine
answer can be)
4.Air Conditioner
2.Two wheeler Motor cycle
3.Car
5.Others(specify)
14 Approximately, how 1.1500-5000
much is the average
spending of the 2.5000-9000
household per month?
3.9000 And above.
15. What is the 1.SC/ST
community you 2.General
belong to? 3.OBC
4.Others(specify)
XII
99. Don’t know/No
response/Refuse to respond
16. Are you participating 1.Yes
in any self help group
like Kudumbasree/
Janasree/ Sreesakthi? 2. No
17. What is your working pattern daily?
a. Not doing any 1.Yes Yes=Sedentary
physical work. 2.No
b. Mild nature of 1.Yes Yes=Mild PA
work?(doing either 2.No
domestic work or
caring household)
c. Moderate nature of 1.Yes Yes=Moderate
work?(doing domestic 2.No PA
work and caring
household objects)
d. Severe nature of the 1.Yes Yes=Vigorous
work? (Doing 2.No PA
domestic work, caring
household objects and
higher level in
physical activity in
remunerable or non
remunerable
employment).
18 What is your dietary 1.Vegetarian
pattern? 2.Non Vegetarian
19. Are you controlling 1. Yes
High fat diet? 2. No
20. Are you controlling 1.Yes
high sugar diet? 2.No
SECTION D. Reproductive and menstrual History
Sl Question Response Ma Instructions

no. rk
An
sw
er
1. Do you ever have menstrual 1.Yes
irregularities during menstrual years 2.No
except during pregnancy and lactation or
any known pathology?
2. What was the nature of irregularity you 1. Heaviness of
had? (past asking history of menstrual flow during
cycle 3years before)-can be multiple menstrual
answers. period.
2. Bleeding in
XIII
between two
menstrual cycles
or experiencing
frequent
menstrual
periods.
3. Scanty blood
flow during
menstrual
period.
4. Pain with
menstrual
bleeding.
3. How many pregnancies have you had? 1.None
2.One
3.Two
4.Three
5. Four and
more.
4. How many live births did you have? 1.One
2.Two
3.Three
4.Four and more
99. Not
applicable.
5. What was the type of delivery?(specify 1.Vaginal
the number of each type of delivery in Delivery-
the right) 2.Caesarean
section-
3.Others(specify
)-
6. Did you have any complication during 1.Yes
the last Delivery? 2.No
7 Have you ever used any contraceptive 1.Yes
method in the past? 2.No
8 Gynecological morbidity, health care seeking(history of
gynecological disorders and health care seeking for the problem)
Type of Ever When did you Sought Place of Type of

gynaecological had have that care care (list of management
morbidity or problem& (Yes/No institutions) (Medical/Sur
Place of ) ****PPHC/ gical/Others)
ever
Diagnosis*(P PSHF/PTH
diag H/PR/PD). F/PVC/PVS
nose T/AYUSH/
d Others.
XIV
(Yes
/No)
8a. Uterine fibroid

8b. Ovarian cyst
8c. Uteri vaginal

prolapse
8d. Others(specify)_
______
Note*- PH (Public Health facility) PR (Private Health facility),PD ( Private doctor

clinic),Others.
**-PPHC(public primary health centre),PSHF(Public Secondary Health
Facility),PTHF(Public Tertiary Health Facility),PVC(Private Clinic),PVST(Private
Hospital, Secondary/Tertiary),AYUSH, Others.
If you underwent surgery, for any of the 1.Hysterectomy
above condition, 2.Hysterectomy with oophorectomy
99 9.
Can you tell what kind of surgery? 3. Oopherectomy only.
4.Others (specify)
10. When was the (month and year) surgery? ____________
SECTION E. Self Reported Medical Condition
Sl Questions Response Mark

no Answer
1. Waist circumference ___________________________cm
2. Have you ever been diagnosed or treated for the following diseases?(reported that
on medicine or showing medicine prescription or medical report if available)
Medical condition Ever When did you have Sought Which is the health
had(Yes/ that care(Yes/No) care facility,
No) problem(Month you are taking
&Year) treatment/Place of care
(list of institutions)
**PPHC/PSHF/PTHF/
PVC/PVST/AYUSH/
Others.
2a. Hypertension
2b.Diabetes mellitus
2c. Blood cholesterol
XV
variations.
2d.Others(specify)
Note**-PPHC(public primary health centre),PSHF(Public Secondary Health

Facility),PTHF(Public Tertiary Health Facility),PVC(Private
Clinic),PVST(Private Hospital, Secondary/Tertiary),AYUSH, Others.
Malignant Conditions and the Process of screening.

Malignant condition Ever screened for Ever If Yes, Current status
related to reproductive the cancer(Yes/No) Diagnosed(Y (on treatment//treated
organs es/No ) completely/
remission)
3a.Breast cancer
3b.Ovarian cancer
3c.Endometrial/uterine
cancer
3d.Cervical cancer
3e.Others(specify)
SECTION F.Knowledge, Attitude, Perception about Menopause
Sl Question Response (Mark

no. corresponding
correct
answer)
Knowledge and attitude towards menopause to all women
1. Have you heard the term 1.Yes
‘Menopause’ 2.No
2. If yes, what is menopause? 1.Natural Process
2.Pathology
3.Side effects of medicine
4. Pollution in the environment.
5. Others(specify)
6.Donot know
3. Does menopause cause health 1.Yes

problems for the women? 2.No
99.Donot know
4. Should such menopause 1.Yes
related health problem be 2.No
treated? 99.Do not know
Perceptions of Menopause and related symptoms
5. You have now reached 1.It was not different from earlier
menopause. Thinking about times
the phase when you were 2.It was a very difficult phase of
going through it, how would
my life
XVI
you describe it? 3. Do not want to say anything
(How do you feel this period?) about it.
6. When you were experiencing 1.Short time
symptoms of menopause, how 2.Long time
long did you think it would 3.Improve in time
last?
(acute/chronic)
7. I would like to know of the
your frequency of these
symptoms.(can you say what
type of pattern you think you
have)
7.1 Symptoms followed a
regular repetitive pattern (can 1.Yes
be predicted) 2.No
7.2 Symptoms seem to come 1.Yes
whenever (cannot be 2.No
predicted) 1.Yes
7.3. Symptoms were
sometimes predictable but 2.No
some times not 1.Yes
7.4 Some symptoms were 2.No
predictable, some were not
8. Can you describe the way
these symptoms affect you
and your everyday
life?(multiple answer can be) Scoring
1.Yes 2.No
1. Symptoms have major One Yes-1
consequences on life. 1.Yes 2.No Two Yes-2
2. Symptoms have serious Three Yes-3
financial consequences. 1.Yes 2.No
3 .Symptoms cause
difficulties for those who are .
close to me.
9. What do you think that can do 1. The course of illness depends
with your symptoms?(control on me.
over symptoms) 2. Nothing I do will affect my
illness.
3. I have the power to influence
my illness.
99. Do not know/Refuse to
answer.
General Health Care Seeking Behaviour
10. If you are experiencing any 1.Religious leaders
symptoms and you feel you 2.Traditional healers
want treatment or remedy 2.AYUSH
where you will prefer to go?
3.Medicine Pharmacy
XVII
5.Modern medicine(health care
facility)
6.Others(specify)
11. In the past 12 months, how 1.Never

many times did you see a 2.One-three times
doctor or other healthcare 3.Four-six times
Professional primarily for 4.Seven-nine times
treatment of your menopausal
5.Ten or more times
symptoms?
12. How satisfied are you with 1.Satisfied
. your access, treatment to 2.moderately satisfied
health services available to 3.Not at all satisfied
you?
SECTION G. Menopause Related Symptom Questionnaire –The Green Climacteric

Scale.
Women having irregular menstrual cycle in last one to three year.(menopausal

transition period).
Women attained menopause, and this is six months to one year from the last
menstrual period up to the fifth year (Early post menopausal period).
Women attained menopause five years before but age is within 60 years (late post
menopausal period).
The Green Climacteric Scale
Now I am going to ask some questions regarding menopause related symptoms. For every
question there are four options. They are not at all, having little, little more and severe.
Please answer accordingly.
Sl Symptoms Not at all A Quite a Extremely Score(0-

no. Little bit 3)
1 Heart beating quickly or strongly
2 Feeling tense or nervous
3 Difficulty in sleeping
4 Excitable
5 Attacks of Panic
6 Difficulty in Concentrating
7 Feeling tired or lacking in energy.
8 Loss of interest in most things
9 Feeling unhappy or depressed
10 Crying spells
11 Irritability
12 Feeling dizzy or faint
13 Pressure or tightness in head or
body.
14 Parts of the body feel numb or
XVIII
tingling.
15 Headaches
16 Muscle and joint pain
17 Loss of feeling in hands or feet.
18 Breathing difficulties
19 Hot flushes
20 Sweating at night
21 Loss of interest in sex
Score:
Psychological (1-11)= Somatic(12-18)= Vasomotor(19-20)= Sexual(21)=
Anxiety(1-6)= Depression(7-11)=
SECTION H: Health seeing behaviour for the above symptoms

Sl Questions Sought Where do you seek treatment if you experienced menopausal
no Care symptoms?
. (Yes/No *Public **Private *** OTHER
) Facility(Pr./S Facility(PC/PS AYUSH(PHF/Pr.H S
r. r. /PTr. /Sp. F) (specify)
/Tr./ F/Sp.M
Sp.F/Sp.M/ /Sp.G/Sp.P)
Sp.G/Sp.P)
1. Psychologic
al
Symptoms
2. Somatic
symptoms
3. Vasomotor
symptoms
4. Sexual
problems
Note:* Public Facility (Pr.-Primary; Sr.-Secondary; Tr.-Tertiary; Sp.F –Speciality family

medicine; Sp.M –Speciality/internal medicine; Sp.G-Speciality Genecology; Sp.P-
Speciality Psychology/ Psychiatry/Ortho).
**Private Facility (PC-Private clinic; PSr.-Private Secondary; PTr.-Private Tertiary;

Sp.F –Speciality family medicine; Sp. M –Speciality/internal medicine; Sp.G-Speciality
Genecology; Sp.P-Speciality Psychology/ Psychiatry/Ortho).
***AYUSH (PHF)-AYUSH public health facility: ***AYUSH (Pr.HF)-AYUSH private

health facility.
XIX
ANNEXURE VIII
, ,695011
` -
സ്ഥലം സർവേ ത഼യത഻ /

/
പഞ്ചഺയത്ത് &
േഺർഡ഻ന്ററ വപര്
,
. .
.
35 60
.
,
.
. ഈ
.
15-25 ,
, ,
, ,
, ,
.
. ,
.
.
.
. ഈ
.
. ഈ
XX
.
( )
.
( )
; 0471 2524234
[email protected]
നന്ദ഻,
;8111818098
,
, ,695011
XXI
-
/
D D M M Y Y Y Y
1) ഈ
2) ഈ , ,
3) ഈ
4) ഈ
സമ്മതപ඀തത്ത഻ൽ ഒപ്പ഻ട്ട഻രഽന്നഽ ഭഺഗം
________________________________
: ___________________________________
:_ __________________________________
: _________/___________/______________
XXII
ANNEXURE IX
, ,695011
-

/
A:
35-60 2017
/
/
?
?
A* B* C* D* E* F*
1
2
3
4
5
.(by
Kish method)
(Note: A*-Women with eligible age group in the household. B*-Number of women from
eligible age group in household, who were present at the time of survey. C*-Name of the
woman who are present in the time of survey. D*-the completed years of women by 2017.E*-
Using for exclusion criteria. F*-asked for willingness to participate.)
XXIII
B:
i
ii
ii
i
i
v
1 1
,
.
.
2
?
2 ( 1 ,
)
? .
,
2
3 1
?
ഈ
4 1
?
2 .
5 ഈ 1
.
?(2014
2
)
6 1 60
.
?
2
.
.
XXIV
/ /
D:
1
2
3
4 1
2
5 1
?
2
3
4
6 1
.
? 2
7. 1
?
2
3
4 ( )
8. 1
? 2
3
4
5
99
9 ഈ 1
2 14
?( 3 14
4
) 5
6
7 ( )
10 1
2
?(
) 3
4
5
XXV
6 . ( )
11 1
2
3
4 . (
5
12. 1
?
(
2
.
)
3
/ /
.
4 ( )
13. 1
2
? 3
4
)
14. 1 1500-5000
2 5000-9000
3 9000
15 1 /
2
?
3
4 ( )
99 / /
16. 1 .
?( ;
2
/
)?
1
.
2
17.
?
3
4
18 1 .
? 2
XXVI
19 1
2
?
20. 1
2
?
D: ആർത്തേ ඀പതൿഽത്പഺദന ചര഻඀തം
1 , , 1
22 2
?(
)
2 ? 1
(
.) 2
4
.
3. 1
?
2
3
4
5
4. 1
?
2
3
4
99
5. 1
,
? 22 2
4 ( )
6.
1
XXVII
? 2
7. 1
?
22 2
8.
( / )
?
? /
PPHC/PS
) ( /
HF/PTHF/ /
PVC/PVS )
T/AYUSH/
Others.
8a.
8b.
8c.
8d. (
)
.Note:**-PPHC( ),PSHF( / /
),PTHF( PVC(
),
),PVST( ),AYUSH( ) Others( )
9. 1
?
2
44 4 ( )
____________
10.
( )
XXVIII
D:
1. ______________________cm
2 ?
( ( / (list of institutions)
) ) **PPHC/PSHF/PTHF/
( / PVC/PVST/AYUSH/
) Others.
2a.
2b.
2c.
2d. (
)
Note:**-PPHC( ),PSHF( / /
),PTHF( PVC(
),
),PVST( ),AYUSH( ) Others( )
? /
( / ) ? /
( / )
3a.
3b.
3c.
3d.ഗർഭഺശയമഽഖ അർബഽദം
3e. (
9. 1 വരഺഗത്ത഻ൻററ ഗത഻ എറന്ന

ആ඀ശയ഻ച്ച഻ര഻ക്കഽന്നഽ
(
) 2
3 എന്ററ വരഺഗറത്ത
സവഺധ഼ന഻ക്കഺനഽള്ള ശക്ത഻
എന഻ക്കഽണ്ട്
99 /
റപഺതഽ ആവരഺഗൿ പര഻പഺലനം

10. 1
2
XXIX
, 3
4
? 5
( )
6 ( )
11. 1
2
12
3
?
4
12. ന഻ങ്ങൾക്ക് ലഭൿമഺയ ആവരഺഗൿ 1
വസേനങ്ങ , ച഻ക഻ത്സ
എന്ന഻േയ഻ൽ എ඀തവത്തഺളം
സംതൃപ്ത഻യഽണ്ട്? 22 2
F-
, ,
എലലഺ സ്ത඀ത഼കളുറെയഽം ക്കഽറ഻ച്ചുള്ള അറ഻േഽം മവനഺഭഺേേഽം
1. 1
2
2. എങ്ക഻ൽ, എന്തഺണ് 1
ആർത്തേേ഻രഺമം?
2
3
4
5 ( )
3 ആർത്തേേ഻രഺമം 1
സ്ത඀ത഼കൾക്ക് .
ആവരഺഗൿ඀പശ്നങ്ങൾ
2
ഉണ്ടഺകഽന്നഽവണ്ടഺ? 39 99
4. ആർത്തേേ഻രഺമം 1
?
2
XXX
99
ആർത്തേേ഻രഺമം, ബന്ധറപ്പട്ട ലക്ഷണങ്ങൾ
5.
. ഈ
1
2 എന്ററ ജ഼േ഻തത്ത഻റല േളറര

, ඀പയഺസകരമഺയ ഘട്ടമഺയ഻രഽന്നഽ
?
(ഈ
3 അത഻റനക്കഽറ഻ച്ച് എറന്തങ്ക഻ലഽം
?)
പറയഺൻ ആ඀ഗഹമ഻ലല
6. 1
, 22 2
?
3
7. ഈ 1
( )
.(
22
) 2
( )
3
,
.
4 ,
8. ഈ ലക്ഷണങ്ങൾ ന഻ങ്ങളുറെ
ദദനംദ഻ന ജ഼േ഻തറത്ത
ബഺധ഻ക്കഽന്ന ര഼ത഻ ന഻ങ്ങൾ
േ഻േര഻ക്കഺവമഺ? (ഒന്ന഻ലധ഻കം
ഉത്തരം ഉണ്ടഺകഽം)
Score; Any
One yes
Answer-1
Two yes
ലക്ഷണങ്ങൾ ഗഽരഽതരമഺയ .
answer-2
സഺമ്പത്ത഻ക ඀പതൿഺഘഺതങ്ങൾ
Three yes
ഉണ്ടഺക്കഽന്നഽ.
answer-3
9. 1 വരഺഗത്ത഻ൻററ ഗത഻ എറന്ന

ആ඀ശയ഻ച്ച഻ര഻ക്കഽന്നഽ
XXXI
( 2
)
3 എന്ററ വരഺഗറത്ത
സവഺധ഼ന഻ക്കഺനഽള്ള ശക്ത഻
എന഻ക്കഽണ്ട്
99 /
റപഺതഽ ആവരഺഗൿ പര഻പഺലനം

10. 1
,
2
3
4
? 5
( )
6 ( )
11. 1
2
12
3
?
4
12. ന഻ങ്ങൾക്ക് ലഭൿമഺയ ആവരഺഗൿ 1
വസേനങ്ങ , ച഻ക഻ത്സ
എന്ന഻േയ഻ൽ എ඀തവത്തഺളം
സംതൃപ്ത഻യഽണ്ട്? 22 2
G.
( ).
(
).
60
No.
(0-3)
XXXII
1
3
4
5
6.
7. ക്ഷ഼ണം
അനഽഭേറപ്പെഽന്നഽ
അഥേഺ
കഽറേഽ
8
തഺത്പരൿം നഷ്ടറപ്പട്ടു
9 അഥേഺ
അസന്തഽഷ്ടമഺയ
വതഺന്നഽന്നഽ
10
11
12
.
13
14
15
16 സന്ധ഻കള഻ലഽം
വപശ഻കള഻ലഽമഽള്ള
വേദന
17
(
).
18
19
20
21
XXXIII
 (1-11)= (1-6)
o (7-11)
 (12-18)=
 (19-20)=
 (21)=
H:
.
( *Public **Private *** OTHERS
/ ) (specify)
Facility(Pr./Sr. Facility(PC/PSr. AYUSH(PHF
/Tr./ /PTr. /Sp. F/Sp.M /Pr.HF)
Sp.F/Sp.M/ /Sp.G/Sp.P)
(
Sp.G/Sp.P)
/
)
1.
2.
3.
4.
Note:* Public Facility (Pr.-Primary; Sr.-Secondary; Tr.-Tertiary; Sp.F –Speciality family medicine;
Sp.M –Speciality/internal medicine; Sp.G-Speciality Genecology; Sp.P-Speciality Psychology/
Psychiatry/Ortho).
**Private Facility (PC-Private clinic; PSr.-Private Secondary; PTr.-Private Tertiary; Sp.F –
Speciality family medicine; Sp. M –Speciality/internal medicine; Sp.G-Speciality Genecology; Sp.P-
Speciality Psychology/ Psychiatry/Ortho).
***AYUSH (PHF)-Ayush public health facility: ***AYUSH (Pr.HF)-AYUSH private health
facility.
XXXIV
ANNEXURE X
XXXV
XXXVI

Menopause Related Symptoms and Their Correlates: A Community Based Cross Sectional Study in Kollam District, Kerala

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Menopause Related Symptoms and Their Correlates: A Community Based Cross Sectional Study in Kollam District, Kerala

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MENOPAUSE RELATED SYMPTOMS AND THEIR CORRELATES:

A COMMUNITY BASED CROSS SECTIONAL STUDY

ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES

Chapter 1 Introduction 1-5

Figure Title Page No.

3.2 Outline for Sample population recruitment. 25

3.3 Description of Chittumala Block-Gramapanchayat wards 25

3.4 Description of KottakkaraBlock-Gramapanchayat wards 26

3.5 Description of Oachira Block –Gramapanchayat wards 26

3.6 Ascertainment of Menopausal Stages in the study 30

3.7 Procedure of waist circumference measurement 35

4.2 Distribution of Menopause related symptoms by GCS scale 50

Table Title Page No.

AYUSH Ayurveda, Yoga and naturopathy, Unani,

CVD Cardio Vascular Diseases

FMP Final Menstrual Period

GCS Green Climacteric Scale

HDL High-Density Lipoprotein

MRS Menopause related symptoms

NFHS National Family Health Survey

NSSO National Sample Survey Office

STEPS Stepwise approach to Surveillance

STRAW Stages of Reproductive Aging Workshop

VMS Vasomotor symptoms

WHO World Health Organization

Introduction: Menopause is a biological event characterized by complexity of

Demographic transition is a recent phenomenon in developing countries

characterized by decline in fertility, mortality and increase in life expectancy. The

impact of demographic transition on women‘s status is important in terms of

changes in marital status, increased dependency ratio, changes in disease pattern,

health needs of women are different and it is neglected in developing countries

by Cairo Declaration of Population and Development.(ICPD, 1994) and United

Nations Sustainable Developmental Goals(United Nations, 2015).

Menopause is considered to be a marker of biological ageing in women(WHO

reproductive life cycle where there is a transition from reproductive to non

reproductive stage. This brings in a number of physiological changes that affect

process of non-communicable disorders. Historically the association of menopause

and its symptoms was noted by John Leake in 1777(Leake, 1777) .

Natural menopause is indicated by the permanent cessation of menstruation due to

one continuous year of amenorrhea. It is difficult to find a biological marker for

1999a). The complexity of various factors such as hormonal, psychological, social,

outcomes (Utian, 1997).

number of women in the postmenopausal ages 50–59 years is projected to increase

from 36 million in 2000 to 63 million in 2020.(Khandelwal, 2013).

number is not insignificant and runs to millions of women, it is important to have

a national policy with individualized approach in addressing the menopause

expectancy. The quality of the menopause experience of women is determined by

lifestyles, the socioeconomic circumstances , and their access to adequate health

care (Kaufert, 1996).

change in the morbidity pattern in middle life of woman. The proportion of

women who experience pre mature menopause either due to biological or

otherwise induced reasons have long duration of exposure to menopause leading

to severe symptoms, when compared to women who have undergone menopause

naturally. The Reproductive, Maternal, Newborn, Child, and Adolescent Health

(RMNCH+A) programme strategy which is based on ‗Continuum of care‘

by all existing health care programmes.

age at menopause was estimated to be 47.95 years(Subrahmanyam and Padmaja,

woman in Kerala, approximately 28 years of will be spend in the post menopause

physiological event, but its psychological, physical consequences will prevail