Assessment of Menopausal Symptom Using Modified Menopause Rating Scale among Rural Women of Rajnandgaon in Chhattisgarh, a Central India Region

INTRODUCTION

The World Health Organization defines menopause as “The permanent cessation of menstruation as a result of the loss of ovarian activity.”¹ Menopause is a natural process that results in atresia of almost all oocytes in ovaries, causing an increase in follicle-stimulating hormone and luteinizing hormone levels and a decrease in estrogen levels. This decrease in estrogen levels leads to perimenopausal symptoms of hot flushes, insomnia, mood changes, generalize physical, and mental exhaustion as well as postmenopausal symptoms, such as vaginal atrophy, bladder problems, and osteoporosis.²

With increasing life expectancy and age at menopause remaining relatively unchanged, women spend little less than half of her life in the postmenopausal period.³ However, majority of women are not aware of the changes brought by menopause because being old and being women, they face a burden of social inequalities and social discrimination from womb to tomb. In India, there is no current national health program running to serve postmenopausal women-specific health needs. Moreover, a very few studies have been conducted in rural areas to address this issue at deeper level; therefore, this study is an effort to assess the magnitude of suffering due to menopause by using modified menopause rating scale (MRS) among rural women of Rajnandgaon in Chhattisgarh, a Central India Region. Although Chhattisgarh is a fast-developing tribal state, however, 77% population still live in village.It is also a one of the eight high-focus states for family planning with high TFR and high MMR.

MATERIALS AND METHODS

This is an observational cross-sectional study conducted from April 2019 to October 2019 in the department of Obstetrics and Gynecology, BRLSABV Memorial Government Medical College Rajnandgaon, Chhattisgarh, India. A total of 200 women aged between 40 years and 65 years were enrolled for the study who attended gynecology OPD and IPD and gave consent to participate in the study except one.

The exclusion criteria were pregnant and breast-feeding women, women with induced menopause, premature menopause, women on HRT, and uncontrolled medical conditions such as hypertension, diabetes mellitus, heart disease, cancer therapy, history of drug addiction or alcohol abuse. Institutional ethical committee approved the study.

MRS was used as a basis for assessing menopausal symptoms for this questionnaire-based study. MRS is a self-administered instrument that is validated scale and has been used in many clinical and epidemiological studies and in research on the etiology of menopausal symptoms to assess the severity of menopausal symptom.

The MRS is composed of 11 items and is divided into three subscales:

• Somatic—hot flushes, heart discomfort/palpitation, sleeping problems, and muscle and joint problems.
• Psychological—depressive mood irritability, anxiety, and physical and mental exhaustion.
• Urogenital—sexual problems, bladder problems, and dryness of the vagina. Each of the 11 symptoms contain a scoring scale from 0 (no complaint) to 4 (very severe complaint).

All the women who fulfilled the criteria were invited to participate with informed consent. Although the questionnaire was in English, women were interviewed in their own language by trained professionals. Women were asked face to face whether or not they had experienced the 11 menopausal symptoms and depending upon the severity, their symptoms were marked from 0 to 4. However, when questionnaire was asked, initially, most of the women could not respond well, but with repeated explanations, their response gradually increased. Apart from menopausal symptoms, other parameters including demographic data were also collected. Finally, all the parameters were separately analyzed and discussed.

OBSERVATIONS AND TABLES

DISCUSSION

The mean age at menopause in our study was 45.35 ± 4.42 (SD) years. This result is in consistent with an Indian age of menopause that is 46.2 ± 4.9 years as observed by Ahuja,⁴ a PAN India survey IMS 2016. However, our mean age is quite less than that reported in other Indian studies done by, Pal et al.,⁵ Maharashtra, Khatoon et al.,⁶ Lucknow, and Surendar et al.,⁷ Puducherry, where mean age was 48.9 ± 3.2, 50.33 ± 5.26 and 51± 2 respectively. Moreover, menopause occurs somehow earlier in Indian women when compared to Western countries which is slightly higher, 51.14 ± 2.11 years worldwide.⁵ This variation in menopausal age could be due to variation in geography, race, ethnicity, culture, and food habits.

In our study, we used the menopause rating scale (MRS) questionnaire, which has been widely used in many epidemiological and clinical researches while investigating the menopausal symptoms. However, it was noticed that our respondents had difficulties in rating the scales, as out of the total 199 respondents, 141 (70.89%) had no formal education or knowledge about menopausal symptoms. This could be fairly explained by the fact that menopausal symptoms were inversely related to educational level as observed by other studies as well.^6,8

All the participants (100%) had one or more menopausal symptoms in the study. The most common symptom we encountered was muscle and joint pain (90.45%). This finding is comparable to the study done by Khatoon et al., Lucknow⁶ and Senthilvel et al., Kochi,⁹ where joint and muscular pain was 87% and 90.7%, respectively. The important factor responsible for this is poor nutritional status of the rural women in our area. Majority of the participants (68.32%) were from lower socioeconomic status which could possibly be the reason behind the higher prevalence of somatic symptoms like muscle and joint pains, etc. in the study population.

In the current study, physical and mental exhaustion were found to be 79.89%, while a study conducted by Pal et al.⁵ Maharashtra and Joseph et al.¹⁰ Karnataka, found physical and mental exhaustion being the highest symptom that was 86.6% and 85.4%, respectively. The differences in results could be due to varied perception of symptoms by respondents and comorbidities associated with age.

It is well documented that urogenital symptoms occur due to atrophic changes in vaginal wall and the epithelium of bladder which makes them more prone to infection like UTI and vulvitis. The female urethra and trigone of the bladder shares embryonic origin with vagina which contains estrogen receptors and so are affected by decreased level of circulating oestrogen.¹¹

The second most common problem found in our study is bladder problem (87.93%), which is quite higher than the results observed, respectively (63.17%, 56.6%), in a study done by Surendar et al. Puducherry⁷ and Pal et al. Maharashtra.⁵ The variation in present study can be correlated with illiteracy, low socioeconomic status, poor hygiene, and awareness in this regard.

Hot flushes, generalized sweating, and night sweats are the most common prevalent vasomotor symptoms in menopausal age. The physiological mechanisms contributing to these symptoms in the postmenopausal period are incompletely understood but believed to be the consequences of deficient estrogen levels. These vasomotor symptoms may result in emotional outburst, poor work concentration, and sleep disorders.¹²

In the present study, 66.3% of study population had symptoms of hot flushes which is congruent with the other studies done in rural India.^6,7,13 The prevalence of sleep problem and irritability in was 78.89% in our study which is comparable with the other studies.^7,13

The other symptoms that we found were anxiety (73.86%), heart burn (66.83%), and depression (64.82%). Prevalence of sexual problem was least (60.3%) in our study, probably due to ignorance about the sexual hygiene and the social and behavioral taboos attached to this context.

The possible explanation for these differences in prevalence and severity of menopausal symptoms reported in the study may be due to the geographic, sociodemographic, genetic, and racial differences, besides woman’s attitude and knowledge. However, another important perspective that can explain this varied prevalence of symptoms is the difference in study design, study settings, sample size, menopausal status of respondents, and the tools used in different studies.

CONCLUSION

Although menopausal symptoms are highly prevalent among middle-aged women in this area; however, they remain unnoticed and neglected by the women herself, by the society and health sector as well. Physical symptom (joint and muscle problems) were the most commonly reported ones followed by urogenital symptom, hot flushes, sleep disturbance, and anxiety in the study. This signifies the urgent need of active intervention in this field. Healthcare providers have to be sensitized to physical and mental health needs of middle-aged women to improve their quality of life. Finally, the government could concentrate on providing health services by incorporating components specific to menopause in the national health program in addition to their adolescent and reproductive health program.

LIMITATIONS

The present study is cross-sectional study over a period of 6 months using convenient sampling. Results of the study may not be true representation of the menopausal symptom of the population in general.

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Keywords: Menopausal problems, Menopausal symptoms, Menopause rating scale, Observational cross-sectional study, Rajnandgaon..