Objective: This study had two main objectives: (1) to detect the differences in basic aspects of the reproductive aging process (age at menopause, menopausal symptoms, the medicalization of aging) among women from the region of Madrid, who at the time of the study were living in three different environmental contexts (rural, semiurban, and urban), and (2) to identify the main factors responsible for these differences.
Design: Data from two different research projects have been pooled for the DAMES project (Decesions At Menopause Study), and the Ecology of Reproductive Aging Project. The sample size was 1,142, women 45 to 55 years of age (103 rural, 744 semiurban, 295 urban).
Results: Probit analysis was used to estimate median age at natural menopause in the three contexts. Rural women have a later onset of menopause (rural, 52.07 y; semiurban, 51.9 y; urban, 51.23 y) and significantly higher levels of the symptoms related to declines in estrogen, eg, hot flashes (rural, 56%; semiurban, 43%; urban, 46%; χ2 = 6.717, P = 0.035) or loss of sexual desire (rural, 51%; semiurban, 44%; urban, 41%; χ2 = 24.934, P = 0.001). Conversely, urban women suffer more from symptoms related to stress, eg, impatience (rural, 34%; semiurban, 25%; urban, 45%; χ2 = 41.328, P < 0.001). The medicalization of menopause, measured in terms of both surgical menopause and the use of hormone therapy, is significantly higher in the urban population (surgical menopause: rural, 5.8%; semiurban, 8.7; urban, 10%; χ2 = 16.009, P < 0.001). Despite these differences, levels of postmenopausal hormone therapy use are still somewhat lower than in other West European and North American populations. Two different logistic regression analyses were carried out to identify (1) factors associated with differences in ovarian aging, measured through menopausal status, and (2) factors associated with prevalence of hot flashes with respect to ovarian aging. Parity, body mass index, age, environmental context, and, slightly less so, smoking, alcohol consumption, age at menarche, and marital status all contribute significantly or nearly significantly and independently to the explanation of differences found. For the likelihood of having hot flashes, environmental context, age, education, age at menarche, menopausal status, and postmenopausal hormone therapy use all have a significant or borderline significant effect.
Conclusions: Significant differences have been shown to exist in rural, semiurban and urban settings in the median age at menopause, in basic symptom frequency and type, and in the levels of medicalization of the process of reproductive aging. Within multivariate regression models, it has been shown that body mass index, age, and environmental context all contribute to differences in reproductive aging. The factors associated with ovarian aging and hot flashes are comparable to those in other industrialized populations, although standard interpretations should be expanded to include context-based realties, including (1) the higher levels of modernization of urban women that influence differential behavior with respect to risk factors at menopausal age; (2) the different ecological realities surrounding nutrition, physical activity, and social support that characterize women's period of development; and (3) the differential construction of their identity as women in terms of assertiveness, aesthetic perceptions, and the use of health services. Context does, indeed, matter.