The menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is an important event in the natural processes of women’s life 1. Although menopause is a normal event for women, individual experiences vary, and some women seek medical advice for the management of symptoms 2.
Natural menopause is defined as no menses for 12 consecutive months, with no obvious intervening cause. Most women experience menopause between 45 and 54 years, with an average onset of 51 years 3. It is estimated that, in the year 2030, 1.2 billion will be perimenopausal or postmenopausal, and will increase by 4.7 million a year 4.
The menopause marks a major biological transition in the lives of all women, with potentially deep psychological and socioeconomic changes in their life. Most women think that this time is coupled with unbearable difficulties. This negative perspective of the menopause can lead to enormous anxiety among women 5. Many women during menopause manage their problem by themselves, with only about 10% seeking help from healthcare providers 6.
Attitudes, perceptions, and expectations are part of the psychosocial phenomena surrounding menopause. Health professionals believe that attitudes play an important role in the experience of menopause 7. The attitudes toward it vary across cultures and countries. These differences have been related to female age, parity, and hormonal status as well as to social, economical, cultural, educational, and geographical factors 8. Some ethnic and cultural differences in attitude have been documented, particularly between developing and western countries 9,10. Attitudes toward menopause have been studied for several decades with different results. These studies differ in terms of tools used to assess attitudes, sample population, and study design 11–15.
The aim of this study was (a) to determine the current attitude toward menopause in a group of Iranian women before and during menopause and probable difference with other communities and (b) to identify a number of sociodemographic and contextual factors related to these attitudes. Such information is clearly needed to facilitate the development and implementation of public health policies that focus on improving women’s knowledge regarding menopause and its impact on the quality of life.
Materials and methods
This cross-sectional descriptive study was conducted between February and May 2012 on women aged 45–60 years in Semnan city, central Iran. This city consists of seven districts. To ensure that the sample was representative of the overall population, women were selected from the different districts. Each district is covered by a Primary Health Care (PHC) center. After coordination with these centers, the list of households covered by the seven centers was extracted. Women were selected by the multistage sampling method. At the first step, all seven PHC centers were included. At the second step, 784 clusters (households) were selected randomly using systematic sampling technique. Finally, from each household, a woman aged 45–60 years was selected randomly. If there was no woman with the defined age, the next household was selected until the calculated sample was attained.
The menopausal status was defined on the basis of the WHO criteria: (a) premenopause – women who had regular menstrual periods in the last 3 months; (b) perimenopause – absence of menses in at least three cycles but no more than 11 during the past 12 months; and (c) postmenopause – women who had no periods in the last 12 months or longer 3. Women who had undergone hysterectomies were treated as postmenopausal.
After calling and attending women in PHC centers, the aim of the study was described to them. Eligible participants were interviewed face-to-face by trained female interviewers using semistructured questionnaires. This questionnaire was designed by the researchers, guided by different questionnaires included in other previous studies. The reliability of questionnaire was ascertained by means of pilot testing using a selected group of women which were excluded from study. Its validity was confirmed by two experts’ panel.
The questionnaire was divided into two parts. The first part contains sociodemographic data consisting of age, educational level, place of residency, marital status, employment, and menopausal status. The second part was an attitude scale consisting of 17 questions. For each item, women were asked to indicate the degree to which they agree with each item on a five-point (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree) scale. This five-point Likert scale ranged from 1 (strongly disagree) to 5 (strongly agree). The total attitude score was divided as positive (≥60), neutral (40–59), and negative (<40).
The study was approved by Research Committee of Semnan University of Medical Science. Ethical approval was also obtained from University Ethical Committee. Participants were informed that the questionnaire was confidential and anonymous, and informed consent was obtained.
Statistical analyses were performed using SPSS version 16 (SPSS Inc., Chicago, Illinois, USA). Data were analyzed using the Mann–Whitney U-test and the Kruskal–Wallis test. The P-value of less than 0.05 was considered statistically significant.
Of the 784 participants who fulfilled the criteria, 37 were omitted from the study because of incomplete data. Hence, 747 women were enrolled and interviewed. From these participants, 286 (38.4%) were premenopausal, 126 (16.9%) were perimenopausal, and 335 (44.8%) were postmenopausal. The mean (±SD) age of women was 51.3 (±4.5) years. The majority of women (63.5%) were illiterates or have had low level of education (<9 years). The majority of women (86.3%) were unemployed and 92% were married. The main sociodemographic characteristics of the study population are presented in Table 1.
The mean (±SD) attitude score was 53.3 (±6.8). The majority of women (71%) had neutral attitude, 22.8% had positive, and only 6.3% had negative attitude toward menopause. Most women (82%) believed that ‘Menopause is a usual and natural change in women life’. When comparing this item based on menopausal status, there was significant difference between premenopausal, perimenopausal, and postmenopausal women (P=0.009). More than half of women (52.6%) agreed with the statement that ‘Menopause is a pleasant experience because it improves their status in society and family’. Similarly, more than half of the women (54.1%) believed that ‘After the menopause, a woman gets more interested in community and creational affairs than before’. Only about one-third of women believed that ‘there is no prevention or treatment for symptoms of menopause’. Seventy-seven percent of women agreed that ‘Menopause as natural phenomena should not be intervened by drugs and other treatments’. When being asked about their relationship with their husbands and their sexual life, 55.9% of women agreed that ‘After the menopause, there is no change in sexual relationship’. Associations between variables and attitudes toward menopause are shown in Table 2. Menopausal status, educational level, marital status, place of residency, and employment were not associated with women’s attitude.
Women’s attitudes toward menopause are multidimensional and are influenced by hormonal status, psychological factors, lifestyle, interpersonal relationships, and social and cultural factors. Understanding the similarities and differences among women’s perceptions, attitudes, and expectations improves the delivery of appropriate care and promotes lifestyles and increase the quality of life.
Findings from some previously published study indicated that most women have positive attitude 16–19. In the present study, we found that a high percentage of women had neutral or positive attitude. Similarly, in the study by Sommer et al.20, the majority of respondents had neutral or positive attitude toward menopause. This finding can be interpreted in light of the general life context of women and that menopause may simply be one transition in natural life’s course. In contrast, some studies reported that most women have negative attitude toward menopause 21,22. Holmes-Rovner et al.23 reported that African-American women had neither a positive nor a negative view of menopause. The differences between these studies might be because of different types of sampling, population, and cultural differences.
Earlier reports have indicated that attitudes toward menopause significantly differed among categories of education. Some studies have showed that well-educated women have a more positive attitude 24,25. However, other studies indicated that education had a significantly negative impact on menopausal attitudes 26,27. Our study did not show significant association between educational level and attitude. In agreement with this finding, a study on Caribbean women reported little correlation between the level of education and knowledge and attitude 28. Our study population differs from most others as it has low educational levels (63.5% illiterate or not completing high school). Similarly, in their study on the influence of demographic characteristics on women’s attitudes toward menopause, Wilbur et al.29 did not find a significant relationship between women’s attitude and their educational level.
The menopausal status may affect women’s attitudes. The results of this study showed that menopausal status was not significantly related to attitude. Similarly, one study on Swedish women showed that menopausal status was not associated with attitude toward menopause 17. In addition, Bell 30 in his study (USA) did not find association between menopausal status and attitude. These findings are not consistent with most other studies reporting that positive attitude was more common in postmenopausal women, suggesting that experiencing menopause tends to result in more positive attitude 20,24–26,31.
Marital status did not show association with attitude. This is comparable with the data of the study by Eman and colleagues 22,29; they did not report a significant relationship between marital status and women’s attitude toward menopause.
This diversity in the effect of some variables on the attitudes toward menopause reflects the role played by culture in shaping attitudes in different parts of the world. In addition, the type of sampling and study method can affect the result of studies.
This study has a number of limitations that warrant mention. First, this study was cross-sectional. Second, women included in this study cannot be thought of as a random sample of all Iranian women in Semnan, and results cannot be totally extrapolated to the general female population.
Women in our study displayed different attitudes toward menopause, with their general attitudes ranging from neutral to positive. Sociodemographic and reproductive factors were not significantly related to attitudes toward menopause.
The research was supported by Research Committee of Semnan University of Medical Science. The authors thank managers and personnel of Semnan Primary Health Care center.
Conflicts of interest
There are no conflicts of interest.
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