Menopause in Morocco: symptomatology and medical management

Age of despair or age of hope? Palestinian women's perspectives on midlife health

There is limited evidence about women's experiences of the midlife, beyond a narrow - frequently biomedical - focus on the menopause. The broader (physical, social, cultural, political) dimensions of women's midlife health are poorly understood, particularly in low and middle-income countries. Our study seeks to understand how women in the West Bank (occupied Palestinian territories) conceptualise, experience and manage their health in the midlife. We generated qualitative evidence using in-depth life history interviews in 2015 with women (n = 35) living in the West Bank, analysed thematically. Women's understandings of good health draw on indigenous and biomedical knowledge and include a calm psychological state, ease of movement, as well as physical appearance and complexion. Exposure to political violence was understood as impacting mental and physical well-being. Most women articulated a positive view about midlife and ageing as a natural process. A range of terms and expressions were suggested by women experiencing this transition, internalised differently according to marital and motherhood status. For many women, the menopause was merely one - often relatively unimportant - aspect of changes associated with ageing. In dealing with midlife health issues women used multiple strategies, or health pluralism, sequentially or simultaneously; drawing on multiple sets of accrued resources. For never-married or childless women, formal healthcare services represented a site of social exclusion. Our evidence highlights the importance of considering the broader dimensions related to midlife health for understanding women's health maintaining and care-seeking behaviours as they age.

The InterLACE study: Design, data harmonization and characteristics across 20 studies on women's health

OBJECTIVES

The International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events (InterLACE) project is a global research collaboration that aims to advance understanding of women's reproductive health in relation to chronic disease risk by pooling individual participant data from several cohort and cross-sectional studies. The aim of this paper is to describe the characteristics of contributing studies and to present the distribution of demographic and reproductive factors and chronic disease outcomes in InterLACE.

STUDY DESIGN

InterLACE is an individual-level pooled study of 20 observational studies (12 of which are longitudinal) from ten countries. Variables were harmonized across studies to create a new and systematic synthesis of life-course data.

MAIN OUTCOME MEASURES

Harmonized data were derived in three domains: 1) socio-demographic and lifestyle factors, 2) female reproductive characteristics, and 3) chronic disease outcomes (cardiovascular disease (CVD) and diabetes).

RESULTS

InterLACE pooled data from 229,054 mid-aged women. Overall, 76% of the women were Caucasian and 22% Japanese; other ethnicities (of 300 or more participants) included Hispanic/Latin American (0.2%), Chinese (0.2%), Middle Eastern (0.3%), African/black (0.5%), and Other (1.0%). The median age at baseline was 47 years (Inter-quartile range (IQR): 41-53), and that at the last follow-up was 56 years (IQR: 48-64). Regarding reproductive characteristics, half of the women (49.8%) had their first menstruation (menarche) at 12-13 years of age. The distribution of menopausal status and the prevalence of chronic disease varied considerably among studies. At baseline, most women (57%) were pre- or peri-menopausal, 20% reported a natural menopause (range 0.8-55.6%) and the remainder had surgery or were taking hormones. By the end of follow-up, the prevalence rates of CVD and diabetes were 7.2% (range 0.9-24.6%) and 5.1% (range 1.3-13.2%), respectively.

CONCLUSIONS

The scale and heterogeneity of InterLACE data provide an opportunity to strengthen evidence concerning the relationships between reproductive health through life and subsequent risks of chronic disease, including cross-cultural comparisons.

Menopausal symptoms: is spirituality associated with the severity of symptoms?

The aim of this study was to explore whether spirituality was associated with menopausal symptoms. Menopausal symptoms, spirituality, health and menopausal status, and socio-demographic variables were assessed in a community sample of 710 peri- and postmenopausal women. A structural model was explored using structural equation modeling. The results evidence spirituality as a significant contributor regarding the severity of most menopausal symptoms. Among others, spirituality had a significant weight in depressive mood (β = -.414; p < .001), anxiety (β = -.308; p < .001), cognitive impairment (β = -.287; p < .001), aches/pain (β = -.148; p < .001), vasomotor (β = -.125; p = .005) and sexual symptoms (β = -.211; p < .001). Some socio-demographic variables, as well as perceived health, also predicted the menopausal symptoms' severity. Therefore, spirituality can have a positive impact on the menopausal symptoms' reporting.

Features of breast cancer in developing countries, examples from North-Africa

Epidemiological features of breast cancer appear to be different in developing countries compared to Western countries, with notably large proportions of young patients, male patients and aggressive forms of the disease. Using North-Africa (Morocco, Algeria, Tunisia, Libya and Egypt) as an example, we document the magnitude and explore possible explanations for such patterns. Articles and reports published since the seventies were reviewed. Results show that breast cancer incidence in females is 2-4 times lower in North-Africa than in Western countries while incidence in males is similar. Consequently, the relative proportion of male breast cancer is high (≈2% of all breast cancers). Similarly, the incidence of aggressive forms of the disease, like inflammatory or triple negative breast cancer (in females), is not higher in North Africa than in Western countries, but their relative proportion in case series (up to 10% for inflammatory and 15-25% for triple negative) is significantly higher because of low incidence of other forms of the disease. In North Africa, the incidence among women aged 15-49 is lower than in Western countries, but the very low incidence among women aged more than 50, combined to the young age pyramid of North-Africa, makes the relative proportions of young patients substantially higher (50-60% versus 20% in France). Such epidemiological features result mainly from peculiar risk factor profiles, which are typical for many developing countries and include notably rapid changes in reproductive behaviours. These features have important implications for breast cancer control and treatment.

Assessment of symptoms of menopause and their severity among Saudi women in Riyadh

BACKGROUND AND OBJECTIVES

Research on menopause in Arab women is limited. The aim of our study was to assess the commonly experienced symptoms of menopause and their severity among Saudi women.

DESIGN AND SETTING

A cross-sectional study conducted at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Four hundred and ninety healthy women aged 40-55 years and either attending KKUH themselves or accompanying their relatives in outpatient clinics participated in the study. The Menopause Rating Scale (MRS) was used to assess menopausal symptoms and severity.

RESULTS

The mean (SD) age of the women in menopause was 47.9 (6.03) years. The most frequent symptoms were muscle and joint problems occurring in 411 women (83.9%), physical and mental exhaustion in 393 (80.2%), heart discomfort in 358 (73.1%), sleeping disorders in 349 (71.2%), hot flashes in 348 (71.0%), and irritability in 348 (71.0%); in addition, 179 (36.5%) of these women experienced severe psychological distress. Perimenopausal women had higher total and subscales scorings for somatic symptoms than did premenopausal and postmenopausal women (P=.008).

CONCLUSION

The number of Saudi women reporting hot flashes and night sweats was comparable to the number of Western women. In addition, somatic symptoms were more prevalent among perimenopausal than among premenopausal women.

Psychometric properties of the Tunisian-Arabic version of the Women's Health Questionnaire

OBJECTIVES

The Women's Health Questionnaire has been developed for the assessment of symptom perception in mid-aged women. It explores a range of psychological and physical symptoms and is one of the most used health-related quality of life measures. It was developed in the English language and is available in several other languages. The aim of this study was to evaluate the psychometric properties of the Tunisian-Arabic version of the questionnaire.

METHODS

A Tunisian-Arabic translation of the original version of the Women's Health Questionnaire (36-item WHQ) was produced using the forward-backward translation method recommended by the designers. A total of 1231 women were anonymously recruited from the general population using the quota method of sampling. All women were administered the WHQ as part of a broader questionnaire; 1150 records were finally retained for analysis. Psychometric evaluation was performed for the original version of the WHQ (36 items) and then for the 23-item revised version proposed by the MAPI Research Institute.

RESULTS

The acceptability and comprehensibility of the scale were good. The 36-item version showed overall good reliability, but some subscales lacked internal consistency. The validity was explored by principal component analysis and showed significant differences with the original English instrument and some deficiencies in its dimensional structure. The validity of the 23-item revised version was better. Finally, we suggest some adjustments to improve the reliability and validity of the instrument.

CONCLUSION

The Tunisian-Arabic version of the WHQ is globally reliable and valid, but we recommend the use of an improved shortened version, more specific to mid-aged women.

Menopausal symptoms: do life events predict severity of symptoms in peri- and post-menopause?

OBJECTIVE

Hormonal changes during menopausal transition are linked to physical and psychological symptoms' emergence. This study aims to explore if life events predict menopausal symptoms.

METHODS

This cross-sectional research encompasses a community sample of 992 women who answered to socio-demographic, health, menopause-related and lifestyle questionnaires; menopausal symptoms and life events were assessed with validated instruments. Structural equation modeling was used to build a causal model.

RESULTS

Menopausal status predicted only three symptoms: skin/facial hair changes (β=.136; p=.020), sexual (β=.157; p=.004) and, marginally, vasomotor symptoms (β=.094; p=.054). Life events predicted depressive mood (β=-.391; p=.002), anxiety (β=-.271; p=.003), perceived cognitive impairment (β=-.295; p=.003), body shape changes (β=-.136; p=.031), aches/pain (β=-.212; p=.007), skin/facial hair changes (β=-.171; p=.021), numbness (β=-.169; p=.015), perceived loss of control (β=-.234; p=.008), mouth, nails and hair changes (β=-.290; p=.004), vasomotor (β=-.113; p=.044) and sexual symptoms (β=-.208; p=.009).

CONCLUSIONS

Although women in peri- and post-menopausal manifested higher symptoms' severity than their pre-menopausal counterparts, only three of the menopausal symptoms assessed were predicted by menopausal status. Since the vast majority of menopausal symptoms' severity was significantly influenced by the way women perceived their recent life events, it is concluded that the symptomatology exacerbation, in peri- and post-menopausal women, might be due to life conditions and events, rather than hormonal changes (nonetheless, the inverse influence should be investigated in future studies). Therefore, these should be accounted for in menopause-related clinical and research settings.

Symptom clusters at midlife: a four-country comparison of checklist and qualitative responses

OBJECTIVE

The purpose of this study was to examine the frequency and clustering of somatic symptoms as reported by women aged 45 to 55 years in four countries, to compare women's responses to open-ended questions with those derived from structured checklists, and to assess the extent to which bodily symptoms grouped with emotional complaints.

METHODS

The Decisions at Menopause Study recruited 1,193 women from the general population in Beirut, Lebanon; Rabat, Morocco; Madrid, Spain; and central Massachusetts. Women participated in semistructured interviews on health, menopause, and bodily changes at midlife. The women's responses to symptom checklists and their statements in response to open-ended questions were analyzed through factor and textual analyses.

RESULTS

There was considerable consistency between the frequencies of quantitative and qualitative responses, and analyses of qualitative data illustrate the extent to which women associate somatic and emotional complaints. As shown in their responses to the open-ended questions, the women in Massachusetts and Spain did not often cluster somatic with emotional symptoms. In Morocco, dizziness, fatigue, and headaches were clustered with emotional symptoms. Women in Lebanon explicitly associated shortness of breath, chest pain, palpitations, dizziness, fatigue, gastrointestinal complaints, headaches, and, to a lesser extent, joint pain and numbness with emotional symptoms.

CONCLUSIONS

The number of volunteered symptom responses was small because the respondents were relatively healthy; however, the extent and pattern of association between somatic and emotional symptoms varied across sites. Certain somatic symptoms may be more likely to communicate psychosocial distress in particular cultures. These results have implications for patterns of healthcare utilization.

The impact of education, cultural background, and lifestyle on symptoms of the menopausal transition: the Women's Health at Midlife Study

AIMS

This study aimed to examine differences in symptom clusters among women in midlife from different cultural origins and to identify sociodemographic, lifestyle, and health characteristics that could account for the differences between the cultural groups in symptom reporting.

METHODS

Israeli women aged 45-64 were randomly selected according to age and population strata of three groups: long-term Jewish residents (LTR), Jewish immigrants from the former Soviet Union, and Arab women (mostly Israeli-born). Interviews were conducted with 540 LTR, 151 immigrants, and 123 Arab women. The survey instrument included the occurrence and rating of how bothersome to everyday function were 16 symptoms. Three outcome variables included hot flashes and two scales for mental and somatic symptoms extracted from exploratory factor analysis.

RESULTS

Multivariate logistic regressions showed that immigrants and Arab women (compared to LTR) had a significantly lower risk of reporting hot flashes and mental and somatic symptoms. Menopausal status was related only to hot flashes. Low education and depression were associated with the three symptom scales, whereas nonhealthy lifestyle was related only to somatic symptoms.

CONCLUSIONS

Our main finding is that cultural group is an independent predictor of each of the three menopausal symptom scales. A possible explanation for the lower reporting of symptoms among Arab and immigrant groups is that they differ from the LTR in level of acculturation and attitudes toward menopause. These findings support the proposition of a cultural factor in menopausal symptomatology that needs to be addressed by clinicians caring for women at midlife.

Determinants of hot flashes and night sweats

PRIMARY OBJECTIVE

The purpose of this study was to identify determinants of hot flashes and night sweats, two vasomotor symptoms associated with the hormonal changes of the menopause transition.

METHODS

Participants were 293 women, aged 45 to 55, randomly selected from automated demographic and membership records of a health maintenance organization in the northeast USA. Letters were mailed to eligible women, followed by face-to-face interviews.

RESULTS

Hot flashes during the month before interview were reported by 57% of the participants, although only 9% of the entire sample reported hot flashes to be "bothersome". Night sweats were reported by 36% of all participants, with 6% reporting night sweats to be "bothersome". Fifty-four percent of women reporting hot flashes also reported night sweats. In logistic regression analyses that controlled for menopause status and use of hormone therapy (HT), daily alcohol consumption significantly increased the risk of hot flashes, night sweats, and bothersome night sweats. Higher education and an excellent self-rating of health decreased the risk of night sweats, but not hot flashes. Smoking increased the risk of bothersome hot flashes, but not bothersome night sweats.

CONCLUSIONS

In logistic regression analyses, alcohol consumption was a significant predictor of vasomotor symptoms. A slightly different set of variables were associated with hot flashes compared to night sweats.

The medical management of menopause: a four-country comparison care in urban areas

OBJECTIVE

To compare the medical management of menopause across urban areas in four countries which differ by level of income and degree of medicalization.

METHODS

Surveys of health providers who advise women on the menopausal transition were carried out in Beirut, Lebanon (n=100), Madrid, Spain (n=60), Worcester, MA, U.S. (n=59), and Rabat, Morocco (n=50) between 2002 and 2004. Physician characteristics, hormone therapy (HT) prescribing practices, and concerns about the management of menopause were compared across countries using chi(2) and logistic regression analyses.

RESULTS

Across sites, physicians were generally well informed about HT and thought that symptom alleviation and disease prevention were equally important. They had concerns about risks associated with HT, particularly breast cancer, and in 3 sites where the survey was conducted after the WHI (Beirut, Rabat, and Madrid) physicians changed their practices to prescribe HT less frequently, for shorter durations, or shifted to other medications. There were significant differences across sites in the recommended duration of HT, time spent talking with patients, perceived benefits of HT, tests recommended before prescribing HT, and concern about the risks associated with HT. Physicians in Madrid and Massachusetts were more likely to report that decisions about the management of menopause were difficult, but in all sites the main reason for difficulties was concerns about risks. The results also suggest discrepancies between physicians' perceptions and women's reports about the reasons why women consult at menopause.

CONCLUSIONS

Prescription patterns and perceived benefits of HT appear to reflect local medical culture rather than simply physician characteristics. The impact of the WHI study was seen in prescribing patterns and concerns about HT. Physicians in all four countries were generally well informed. Financial support: NIH 5 900 000196.

Missed symptoms of menopause

OBJECTIVE

This review examines the available data on the efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) for treating the commonly missed climacteric symptoms of menopause.

DISCUSSION

Although some women may pass through the menopausal transition phase with few or no symptoms, the majority experience one or more symptoms serious enough to be disruptive to their lives. The most common are vasomotor symptoms (VMS; hot flushes and night sweats), but they are not the only climacteric symptoms that can negatively affect quality of life. The 'missed symptoms' of menopause -- symptoms with high prevalence and an impact on quality of life that nonetheless receive less attention than do VMS -- include mood changes, sleep disturbances and somatic complaints. These symptoms are reported by approximately half of menopausal women, with numbers varying by region and ethnic background. As with VMS, the effects of declining oestrogen levels on serotonin/noradrenaline pathways could play a role in their development.

CONCLUSIONS

Results from pilot studies of several SSRIs and SNRIs suggest that they may improve menopausal mood and sleep symptoms, but few studies have demonstrated significant improvement compared with placebo. One SNRI (venlafaxine) improved menopausal mood symptoms and two SSRIs (citalopram and paroxetine) improved sleep, each in a single placebo-controlled trial of women with VMS. Additional placebo-controlled trials are needed to determine whether SSRIs or SNRIs are effective treatment options for women who cannot or choose not to use hormone therapy.

Symptoms, menopause status, and country differences: a comparative analysis from DAMES

OBJECTIVE

To investigate reported frequencies of menopausal symptoms among women in four countries, namely Lebanon, Morocco, Spain, and the United States, and to assess the relative role of menopause status, country of residence, and other factors in explaining differences in symptomatology.

DESIGN

Surveys of representative samples of approximately 300 women aged 45 to 55 years in each site were conducted, using an instrument that includes demographic, health, and menopausal variables, in addition to perceptions and attitudes toward menopause. Statistical and textual analyses are used to examine differentials and the factors that influence them.

RESULTS

The burden of symptoms and the frequencies of symptoms differ across sites, but hot flashes are reported everywhere by just under one half of the respondents. The most frequent symptoms are joint pain, fatigue, impatience/nervousness, sleep disturbances, memory loss, and one or more emotional symptoms. Menopause status is significantly associated with hot flashes and vasomotor symptoms and to a lesser extent with emotional and sexual symptoms. Smoking, schooling, employment, and age are also associated with the frequency of selected symptoms. Country of residence influences reported symptoms over and above other factors.

CONCLUSIONS

Similarities among core symptoms and differences in the expression of symptoms were found across sites. Both biological (menopause status) and cultural (country of residence) variables influence symptomatology.

Symptom groupings at midlife

OBJECTIVE

To examine how symptoms at midlife grouped together by factor analyses in four different countries and to examine whether life changes were associated with symptom frequencies.

DESIGN

The Decisions at Menopause Study was a multisite study of women aged 45 to 55 drawn from the general population in the United States, Spain, Lebanon, and Morocco. Semistructured questionnaires collected demographic, reproductive, and lifestyle information, along with 4-week recalls of 25 symptoms. Factor analyses were performed using symptom frequency data from each country. Symptoms frequencies were examined by chi analysis in relation to job, home, and life changes. Regression scores for individual factors were examined as dependent variables in relation to menopause status and life change while controlling for demographic and reproductive variables.

RESULTS

The intercorrelation among symptoms differed in country-specific ways, eg, hot flashes grouped with vaginal dryness and sexual symptoms in Spain, with general somatic symptoms in Morocco, and did not cluster with other symptoms in the United States or Lebanon. In chi2 analyses, household change, not job change, was associated with increased symptomatology in Spain. Job change was a significant predictor of the first symptom cluster in the United States (mental symptoms) and Spain (emotional symptoms). Home change was a significant predictor of the third (mental) symptom cluster in Spain. Life change was a significant predictor of symptom clusters in Spain and Morocco.

CONCLUSIONS

Cross-population comparisons demonstrate variation in symptom clusters. Regression analyses showed how the variables that predict symptom groupings (eg, job change, marital status, menopause status, or level of education) also differed in country-specific ways.

Environmental contexts of menopause in Spain

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 (Decisions 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%; chi2=6.717, P=0.035) or loss of sexual desire (rural, 51%; semiurban, 44%; urban, 41%; chi2=24.934, P=0.001). Conversely, urban women suffer more from symptoms related to stress, eg, impatience (rural, 34%; semiurban, 25%; urban, 45%; chi2=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%; chi2=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, education, 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 hae 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 realities, including (1) the higher levels of modernization of urban women that influence differential behavior with respekt 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.

The roles of biologic and nonbiologic factors in cultural differences in vasomotor symptoms measured by surveys

OBJECTIVE

To review evidence of cultural differences in both biologic and nonbiologic factors as possible explanations for variation across cultures in self-reported vasomotor symptoms from surveys.

DESIGN

Literature review and cross-sectional and longitudinal comparisons of ethnic groups with respect to patterns of symptom reporting from the Study of Women's Health Across the Nation (SWAN).

RESULTS

The evidence to date indicates that cultural differences in vasomotor symptom reporting on surveys reflect both differences in the underlying biology, which ar likely to influence vasomotor symptom occurrence, and differences in nonbiologic sociocultural factors such as attitudes toward menopause, which are likely to be related to vasomotor symptom perception and reporting,

CONCLUSIONS

It is important to consider interactions of culture and biology in studies of vasomotor symptoms. Recommendations for future studies include using both open- and closed-ended questions, including measurements of objective indicators such as reproductive hormone concentrations, measuring both culturally related biologic and nonbiologic factors related to vasomotor symptom occurrence or reporting, and using the same general study protocol for multiple cultural groups being compared.

Prevalence of hot flushes and night sweats around the world: a systematic review

OBJECTIVE

Many studies have evaluated the relationships between ethnicity and culture, prevalence of menopausal symptoms, and attitudes toward them, but few have assessed menopausal symptoms across cultures world-wide. This paper aims to systematically review the prevalence of hot flushes and night sweats, two prevalent symptoms of menopause, across the menopausal stages in different cultures and considers potential explanations for differences in prevalence rates.

DESIGN

Sixty-six papers formed the basis for this review. Studies were organized by geographic region, and results are presented for North America, Europe, East Asia, Southeast Asia, Australia, Latin America, South Asia, Middle East, and Africa. Studies were included if they provided quantitative information on the occurrence of hot flushes. This report focuses on hot flushes and night sweats, the most common menopausal symptoms reported in epidemiologic studies.

RESULTS

Studies reviewed indicate that vasomotor symptoms are highly prevalent in most societies. The prevalence of these symptoms varies widely and may be influenced by a range of factors, including climate, diet, lifestyle, women's roles, and attitudes regarding the end of reproductive life and aging. Patterns in hot flush prevalence were apparent for menopausal stages and, to a lesser degree, for regional variation.

CONCLUSIONS

Caregivers should recognize that variations exist and ask patients specific questions about symptoms and their impact on usual functioning.

The menopause in Spain: Results of the DAMES (Decisions At MEnopause) Study

OBJECTIVE

To assess the symptomatology of menopause and the use of hormone therapy among women in Spain.

METHODS

A survey conducted on a representative sample of 300 women aged 45-55 in Madrid. The instrument included closed- and open-ended questions about demographic and socio-economic information, health and reproductive history, symptoms in past month, use of health services, life style, and therapeutic decisions.

RESULTS

Eighty-three percent of respondents report five or more symptoms. Joint pains, weight gain, mood changes and nervousness are the most frequently reported; just under half of respondents report hot flashes; 4/5 report emotional/mental symptoms. The frequencies of some symptoms vary with socio-economic status. Two-thirds of respondents have consulted physicians, and 10% are currently taking hormone therapy; the use of hormone therapy is lower among women from the lower strata. One-fifth of respondents use of nonconventional and alternative medications. Just under half of respondents find that menopause is difficult.

CONCLUSION

Symptom reporting is relatively high, but general symptoms are more frequent than "core" menopausal symptoms. The use of hormone therapy is relatively low, but the use of alternative medicines is relatively high.

Age at natural menopause in Spain and the United States: results from the DAMES project

Our research was undertaken to determine the median age of natural menopause and correlates of the timing of menopause in Spain and the United States (U.S.). A population-based sample of 300 women from Madrid, Spain and a random sample of 293 women from Fallon Community Health plan (FCHP), a health maintenance organization (HMO) in central Massachusetts, were interviewed using a semi-structured questionnaire. Logit analysis and logistic regression were used to estimate the median age at menopause and identify factors associated with it. The median age of natural menopause in Spain is estimated at 51.7 years, and in the U.S., it is 52.6 years. In Spain, women with any children (OR = 0.58, 95% CI: 0.25, 1.36) and a lower body mass index (BMI) (OR = 0.45, 95% CI: 0.27, 0.78) had later ages at menopause while current smokers (OR = 5.51, 95% CI: 1.82, 16.7) had earlier ages of menopause in a multivariate model. A multiplicative interaction between smoking status and parity was identified, and an interaction term included in the multivariate model (OR = 0.58, 95% CI: 0.35, 0.94). In the U.S., household income, marital status, and education level were statistically associated with age at natural menopause in bivariate models. These factors were no longer statistically significant after adjustments in a multivariate model. Oral contraceptive use, cycle length, and cycle regularity were not statistically associated with the age of menopause in either country. The ages of natural menopause in Spain and the U.S. are comparable to other industrialized nations. The factors associated with the timing of natural menopause, in particular smoking and BMI, are consistent with those identified in previous studies.

Culture and symptom reporting at menopause

The purpose of the present paper is to review recent research on the relationship of culture and menopausal symptoms and propose a biocultural framework that makes use of both biological and cultural parameters in future research. Medline was searched for English-language articles published from 2000 to 2004 using the keyword 'menopause' in the journals--Menopause, Maturitas, Climacteric, Social Science and Medicine, Medical Anthropology Quarterly, Journal of Women's Health, Journal of the American Medical Association, American Journal of Epidemiology, Lancet and British Medical Journal, excluding articles concerning small clinical samples, surgical menopause or HRT. Additionally, references of retrieved articles and reviews were hand-searched. Although a large number of studies and publications exist, methodological differences limit attempts at comparison or systematic review. We outline a theoretical framework in which relevant biological and cultural variables can be operationalized and measured, making it possible for rigorous comparisons in the future. Several studies carried out in Japan, North America and Australia, using similar methodology but different culture/ethnic groups, indicate that differences in symptom reporting are real and highlight the importance of biocultural research. We suggest that both biological variation and cultural differences contribute to the menopausal transition, and that more rigorous data collection is required to elucidate how biology and culture interact in female ageing.

Prevalência e fatores associados a fogachos em mulheres climatéricas e pós-climatéricas

Com o objetivo de determinar a prevalência de fogachos e fatores associados, em mulheres entre 40 e 69 anos de idade, provenientes de uma amostra representativa da população da cidade de Pelotas, Rio Grande do Sul, Brasil, realizou-se um estudo transversal. O processo de amostragem foi em múltiplos estágios, e a coleta de dados, realizada através de entrevista e questionário auto-aplicado. Foram incluídas 879 mulheres. A prevalência ponto e a prevalência de episódio de fogachos foram, respectivamente, de 30,1% e 53,2%. Os fatores estatisticamente associados a fogachos atuais foram a categoria menopausal de pré-menopausa (RP = 2,33) e pós-menopausa (RP = 2,66); idade de 45 a 49 anos (RP = 1,34) e de 50 a 54 anos (RP = 1,42); status sócio-econômico mais baixo (RP = 2,16); não uso de anticoncepção hormonal após os 40 anos (RP = 1,40); obesidade (RP = 1,39); sobrepeso (RP = 1,32) e viver sem companheiro (RP = 0,80). Dada a alta prevalência do sintoma, é necessário que os serviços de saúde se organizem para lidar com a mulher climatérica.

Women with and without menopause over age of 40 in Turkey: consequences and treatment options

AIM

To investigate the characteristics of menopausal population who gets free first step health-care services from government facilities in the Central Anatolia Region of Turkey.

METHODS

One thousand and forty-nine pre- (N = 403) and post (N = 646)-menopausal females were interviewed with a questionnaire in five different facilities during 2 weeks.

RESULTS

The group, who never used oral contraceptive as a family planning method, never smoked and had a low rate of illiteracy (72.5, 72.5, 77.7, and 12.1%, respectively. Mean age of the menopause was 45.8 +/- 5.5 years. Mean years since menopause was 13.2 +/- 9.6 years and mode of the menopause was 10 years. Group of postmenopausal women knew the meaning of menopause as "ceasing of menses" in a significantly higher rate compared to pre-menopausal group (6.9% versus 2.2%, respectively). While rate of the women regularly visiting free health-care facilities and rate of receiving some form of HRT is observed to be relatively low (33 and 29.4%, respectively), no significant differences were observed in symptoms rating between pre- and post-menopausal group restlessness, uneasy feeling, insomnia, flushing, sweating, tachycardia, short memory, bone and muscle pain, and nocturia and therefore such symptoms seem to be unrelated to their menopausal status.

CONCLUSIONS

Women are entering to menopause earlier and using the free medical facilities in this region of Turkey less, compared to European population and seeking less help for menopause during this period. They are mostly married, with lower preferences for oral medications, non-smokers, relatively literate group of people; however, with low awareness of their current situation regarding the phenomenon of "ceasing of menses" and its consequences.

Therapeutic decisions for menopause: results of the DAMES project in central Massachusetts

OBJECTIVE

To investigate the factors that influence therapeutic decisions at menopause, particularly those related to the burden of menopause symptoms, in a population of women living in Massachusetts, as part of the multisite DAMES (Decisions At Menopause Study).

DESIGN

A survey using face-to-face interviews with a randomly selected sample of 293 women aged 45 to 55 who are members of the Fallon Community Health Plan in Central Massachusetts. The instrument combined closed- and open-ended questions and elicited information about a number of health topics, including the symptoms experienced by respondents over the preceding month and the decisions they made regarding therapies.

RESULTS

Symptom reporting was found to be relatively high, with more than half of the sample reporting hot flashes, sleep disturbances, joint pains, and headaches in the month preceding the survey; one third to one half of the women reported palpitations, night sweats, fatigue, and numbness. The highest frequency of symptoms occurred during perimenopause. Nearly four fifths of the women consulted a healthcare provider, and one fifth used hormone therapy. More than half of the respondents said menopause is a difficult phase, and about half found decisionmaking about it to be difficult.

CONCLUSIONS

This study documents a relatively heavy burden of symptoms in a relatively healthy population and provides an update on earlier studies in Massachusetts.

Influences of hormone replacement therapy on postmenopausal women's health perceptions

OBJECTIVE

To assess the beliefs of climacteric women regarding their health, menopause, and hormone replacement therapy (HRT).

DESIGN

Medical students asked to interview 526 healthy women, ranging from 40 to 64 years of age, between January and February of 2002. Of that number, 26 (4.9%) declined to participate in the interview. Thus, 500 women were interviewed about their beliefs and perceptions regarding their quality of life and health risks, as well as their opinions on menopause and HRT.

RESULTS

The mean age of the sample was 53.3 +/- 6.2 years; 83.4% were postmenopausal, and 18.8% were HRT users. Of the women interviewed, 38.6% believed that their health was good. Although 78.8% thought that cancer is the main cause of death, 64% of them considered themselves to be at high risk for cardiovascular disease and osteoporosis. Most (64%) believed that menopause deteriorates the quality of life and that it increases cardiovascular risk (52.4%) and osteoporosis (72.0%). The HRT users perceived that they had better health status (48.9% v 36.2%, P < 0.02) and smaller cardiovascular risk (54.3% v 66.3%, P < 0.04) than did the nonusers; however, they ignored the preventive effect of estrogens in osteoporosis.

CONCLUSIONS

Women believe that menopause deteriorates their health. The HRT users perceived themselves to be healthier and to have a smaller risk for cardiovascular disease.