The quality of life during and after menopause among rural women

Investigating the Prevalence of Menopausal Symptoms and Medico-Social Dimensions of Menopause in Rural Puducherry, India: A Cross-Sectional Analytical Study

Introduction Globally, the health of women has been of great concern for healthcare providers for the past many years. However, the concern is limited to maternal and adolescent health and the life course approach is lagging. Thus, a need was felt to study the changes after menopause and its influential factors by determining the prevalence of menopausal symptoms and medico-socio-cultural dimensions of menopause among perimenopausal and early postmenopausal women. Methodology A cross-sectional analytical study was conducted from February 2014 to April 2015 in a rural area of Puducherry among 148 women in perimenopausal and early postmenopausal stages by complete enumeration using a pre-tested semi-structured questionnaire. Prevalence was expressed as frequency with percentage and the chi-square test was used to find the association among the study variables. Results The prevalence of menopausal symptoms was in 143 (96.6%) women. Backache (62.3%) was found to have a higher prevalence. Physical symptoms (93.2%) were most prevalent. Of the women, 95% were affected by mild symptoms. Regarding medical and social dimensions of menopausal symptoms, socioeconomic status to vasomotor, age of menarche to physical, marital status, and abortion status to sexual symptoms were significant. A positive correlation was seen among the four menopausal symptom domains, except for vasomotor to sexual symptoms. Conclusion Increased prevalence of menopausal symptoms is seen among menopausal women who are unaware of seeking medical advice. Additional emphasis should be placed on implementing programmes that will critically help to sensitize and intensify the awareness of menopause among women in India.

Impact of Menopausal Duration on Salivary Flow Rate, Tooth Loss, and Oral Health-related Quality of Life in Indian Communities

Background

Diminishing hormonal levels after menopause evoke physiological changes in a woman's body. Their effects on the oral cavity are noteworthy, considering symptoms of dry mouth, altered taste perceptions, and tooth loss that may be attributed to reduced salivary flow and alveolar density changes.

Aim

The purpose of this study was to assess changes in salivary flow rate, tooth loss, and oral health-related quality of life (OHRQoL) as menopausal duration increased.

Materials and Methods

A total of 327 women fulfilling the eligibility criteria were chosen from two villages in the Mysuru district, Karnataka. They were categorized into three groups based on menopausal durations. Salivary flow rates, number of teeth lost, and OHRQoL after menopause were assessed and compared at different menopausal durations. Sociodemographic characteristics and oral hygiene practices were recorded to identify potential confounders.

Results

Multivariate analysis demonstrated a significant association between menopausal duration and salivary flow rates (adjusted odds ratio = 2.269). However, no such associations were observed with tooth loss and OHRQoL.

Conclusion

Menopausal duration significantly affects salivary flow rate. Its influence on tooth loss and OHRQoL is, however, less evident. Although strong associations cannot be established, the inevitability of the menopausal state advocates consideration of other major yet modifiable factors to improve oral health.

Does the risk of chronic low back pain depend on age at menarche or menopause? A population-based cross-sectional and cohort study: the Trøndelag Health Study

OBJECTIVE

In most population-based studies of low back pain (LBP), women have a higher risk than men, possibly reflecting hormonal influences. The aim of this study was to explore associations between age at menarche and menopause and risk of chronic LBP.

DESIGN

Population-based cross-sectional and cohort study designs.

SETTING

The HUNT2 and HUNT3 medical surveys of the entire population of Nord-Trøndelag County in Norway.

MAIN OUTCOME MEASURE

Prevalence or risk of chronic LBP, defined as LBP persisting at least 3 months continuously during last year.

PARTICIPANTS

Associations between age at menarche and prevalence of chronic LBP were examined in cross-sectional data from HUNT2, comprising 27 697 women aged 20-69 years, with 7300 women reporting LBP. The corresponding cohort data included 11 659 women without LBP at baseline in HUNT2, with 2353 women reporting LBP at follow-up 11 years later in HUNT3. Cross-sectional data on age at menopause or premenopausal status included 11 332 women aged 40-69 years, with 3439 women reporting chronic LBP. Corresponding cohort data included 7893 women without LBP at baseline, of whom 1100 developed LBP.

METHODS

Associations between age at menarche or menopause and risk of chronic LBP were examined by generalised linear modelling.

RESULTS

A U-shaped association was indicated between age at menarche and risk of chronic LBP, both in the cross-sectional and cohort studies. Age at menarche ≤11 years was associated with an increased risk of chronic LBP, with a relative risk of 1.32 (95% CI 1.15 to 1.52), compared with age 14 years at menarche, after relevant adjustments. Corresponding cross-sectional crude absolute risks were 32% and 25%, respectively. No association was established between age at menopause and risk of LBP. Being premenopausal had no influence on risk.

CONCLUSIONS

In contrast to results for age at menopause, the association with age at menarche suggests that hormonal factors affect the risk of LBP.

Potential differences in somatosensory function during premenopause and early and late postmenopause in patients with burning mouth syndrome: An observational case-control study

Background/purpose

Burning mouth syndrome (BMS) is a chronic condition presenting as intraoral burning or dysesthesia, with a high preponderance in menopausal women. This study aimed to examine the association between somatosensory dysfunction and BMS in premenopausal, early postmenopausal, and late postmenopausal patients, using a standardized Quantitative Sensory Testing (QST) protocol, and to determine the predictive value of thermal or mechanical perception by QST for detecting BMS.

Materials and methods

An observational case–control study was performed with 36 female participants with BMS (12 premenopausal, 10 early postmenopausal, and 14 late postmenopausal) and 42 age- and sex-matched healthy volunteers (21 premenopausal, 10 early postmenopausal, and 11 late postmenopausal). Neurophysiological tests were used to evaluate somatosensory dysfunction at the tongue.

Results

Z-score in the late postmenopausal BMS group revealed a gain of function for the cold pain threshold and heat pain threshold (Z = 2.08 and 3.38, respectively). In the multiple regression analysis with the Visual Analog Scale as the dependent variable, the vibration detection threshold predicted the severity of burning mouth sensation in the premenopausal group.

Conclusion

Late postmenopausal patients with BMS showed an increased response of the tongue to noxious thermal stimuli. This supports the theory that changes in sex hormones may affect trigeminal somatosensory function, particularly during the late postmenopausal stage in patients with BMS.

High-density Lipoprotein Cholesterol as a Risk Factor of Health-Related Quality of Life in 50–70-Year-Old Community-Dwelling Women

BACKGROUND: The prevalence of dyslipidemia, a risk factor of cardiovascular disease, is at present sufficiently high, particularly in the elderly. Health-related quality of life (HRQoL) is also an important outcome in the treatment of dyslipidemia, which is currently more targeted at lowering the low-density lipoprotein cholesterol (LDL-C) concentration. AIM: The aim of this study was to determine the relationship between the high-density lipoprotein cholesterol (HDL-C) concentration and HRQoL in community-dwelling women aged 50–70 years. METHODS: A cross-sectional study involving 137 women aged 50–70 years who underwent blood sampling for determining the concentrations of hemoglobin, total cholesterol (TC), LDL-C, and HDL-C. A questionnaire was given to all subjects regarding data on age, menopausal status, level of education, and also another questionnaire of SF-36 for evaluation HRQoL. Bivariate and multivariate logistic regression analysis was used to identify risk factors associated with HRQoL. RESULTS: In bivariate logistic regression analysis, age, menopausal status, education level, anemia, TC, and LDL-C were found to have non-statistically significant association with HRQoL, but HDL-C was significantly associated with HRQoL (odds ratio = 0.44; 95% Confidence interval [CI] = 0.20–0.97; p = 0.042). In multivariate analysis, menopausal status and education level have a non-statistically significant association with HRQoL, but those normal level of HDL cholesterol was found 0.18 times less likely to be associated with poor HRQoL (Adjusted odds ratio 0.18; 95% CI = 0.03–0.91; p = 0.038). CONCLUSION: This study showed that HDL-C levels were risk factors of HRQoL in women 50–70 years of age.

Can Resistance Exercise Be a Tool for Healthy Aging in Post-Menopausal Women with Type 1 Diabetes?

Due to improvements in diabetes care, people with type 1 diabetes (T1D) are living longer. Studies show that post-menopausal T1D women have a substantially elevated cardiovascular risk compared to those without T1D. As T1D may also accelerate age-related bone and muscle loss, the risk of frailty may be considerable for T1D women. Exercise and physical activity may be optimal preventative therapies to maintain health and prevent complications in this population: They are associated with improvements in, or maintenance of, cardiovascular health, bone mineral density, and muscle mass in older adults. Resistance exercise, in particular, may provide important protection against age-related frailty, due to its specific effects on bone and muscle. Fear of hypoglycemia can be a barrier to exercise in those with T1D, and resistance exercise may cause less hypoglycemia than aerobic exercise. There are currently no exercise studies involving older, post-menopausal women with T1D. As such, it is unknown whether current guidelines for insulin adjustment/carbohydrate intake for activity are appropriate for this population. This review focuses on existing knowledge about exercise in older adults and considers potential future directions around resistance exercise as a therapeutic intervention for post-menopausal T1D women.

A Cross-Sectional Study to Assess the Quality of Life of Perimenopausal and Post menopausal Women in Rural Etawah, Uttar Pradesh, India

Background:

Perimenopause is the period in a woman's life during which she passes from the reproductive to the nonreproductive stage. According to the 2008 estimates, the number of menopausal women in India was 43 million. Projected values in 2026 depict the menopausal population at 103 million. Due to the increasing life expectancy, improved quality of life is imperative to decrease the disability and frailty of a society.

Objectives:

To study the quality of life of perimenopausal women in rural areas of Etawah district, Uttar Pradesh, and the various factors associated with it.

Materials and Methods:

This is a community-based cross-sectional study conducted in 4 villages in the Saifai block of Etawah district, Uttar Pradesh, India. One hundred and ninety-nine healthy, perimenopausal women of the age group 45–55 years were included in the study. Data were collected on sociodemographic variables, and Menopause Specific Quality of Life Questionnaire - Intervention version questionnaire was used to assess the quality of life.

Results:

The mean age of attainment of menopause was 45.38 ± 3.58 years. Majority of the women experienced physical (100%) and psychosocial (94.5%) symptoms; the most common symptom being “decrease in physical strength” (86.4%) and being able to “accomplish less than previously” (80.4%). Women who handled stress poorly showed severe vasomotor (P = 0.047) and psychosocial (P = 0.014) symptoms. Postmenopausal women who regularly exercised were 52.6% less likely to have vasomotor symptoms (odd's ratio OR 0.474 (0.235–0.960), P = 0.038).

Conclusion:

The quality of life among the study population was affected by the physical and psychosocial problems they experienced. By taking appropriate preventive measures, these can be ameliorated, and further deterioration can be checked.

Musculoskeletal Pain during the Menopausal Transition: A Systematic Review and Meta-Analysis

Musculoskeletal pain (MSP) is one of the most severe complaints in women undergoing menopause. The prevalence of MSP varied when taking the menopausal state and age factor into consideration. This study investigated the prevalence of MSP in perimenopausal women and its association with menopausal state. The MEDLINE, Embase, Web of Science, and PubMed databases were searched from inception to July 2020, and 16 studies were retrieved for the current meta-analysis. The primary outcome measure was the MSP Odds Ratio (OR). The estimated overall prevalence of MSP among perimenopausal women was 71% (4144 out of 5836, 95% confidence interval (CI): 64%-78%). Perimenopausal women demonstrated a higher risk for MSP than premenopausal ones (OR: 1.63, 95% CI: 1.35-1.96, P = 0.008, I² = 59.7%), but similar to that in postmenopausal ones (OR: 1.07, 95% CI: 0.95–1.20, P = 0.316, I² = 13.4%). The postmenopausal women were at a higher risk of moderate/severe MSP than the premenopausal ones (OR: 1.45, 95% CI: 1.21-1.75, P = 0.302, I² = 16.5%) or the perimenopausal ones (OR: 1.40, 95% CI: 1.09–1.79, P = 0.106, I² = 55.4%). In conclusion, the perimenopause is a state during which women are particularly predisposed to develop MSP. As to moderate to severe degrees of MSP, the odds increase linearly with age, from premenopause to peri- and then to postmenopause.

Concomitants of menopause-specific quality of life in premenopausal and post-menopausal women living in South Korea

The present study investigated the concomitants of menopause-specific quality of life among premenopausal and postmenopausal women. Based on the Wilson and Cleary model of quality of life, this cross-sectional study recruited 329 women of age 40-65 years following operational convenience. The study was conducted in the office of the Korea Population, Health and Welfare Association (KPHWA) in Incheon, South Korea. Data collected on sociodemographic characteristics, social support, biological/physiological characteristics, the Pittsburgh Sleep Quality Index (PSQI-K), and self-rated health. Menopause-specific quality of life questionnaire (MENQOL) was used in this study. Hierarchical multiple linear regression analysis was performed. The study found that social support and self-rated health were negatively correlated with MENQOL in premenopausal women, while the income level and self-rated health were negatively associated with MENQOL in postmenopausal women. Sleep quality was positively correlated with MENQOL in both premenopausal and postmenopausal women. The study results indicate the need for tailored approaches based on menopausal status. Especially, social support may help improve the MENQOL of premenopausal women, while in postmenopausal women, improved sleep quality may enhance their menopause-specific quality of life.

Combination of Red Clover and Hops Extract Improved Menopause Symptoms in an Ovariectomized Rat Model

Red clover and hops are already known for their alternative menopausal therapies; however, their combination has not yet been studied. This study aimed to evaluate the efficacy of the combination of red clover and hops extract (RHEC) for treating menopausal symptoms for the first time. A high-performance liquid chromatography (HPLC) method for RHEC was developed and validated for the analysis of biochanin A in red clover extract and xanthohumol in hops extract. An in vivo study was conducted using an ovariectomized rat model treated with RHEC (125, 250, and 500 mg/kg, p.o.) for a 12-week test period. Changes in body weight, tail skin temperature (TST), serum lipid profile, bone metabolism, antioxidants, and markers of vasorelaxation and uterus endometrium were evaluated. RHEC significantly inhibited body weight gain and decreased fat weight. Changes in TST associated with flashes were significantly inhibited in the RHEC groups. Other markers related to menopausal symptoms, such as blood lipid profile (total cholesterol and low-density-lipoprotein cholesterol), bone metabolism (serum alkaline phosphatase, osteocalcin, and c-terminal telopeptide type 1), antioxidants (superoxide dismutase and malondialdehyde), and vasorelaxants (endothelin-1 and nitric oxide), were significantly improved after the administration of RHEC. We also confirmed the safety of RHEC through histopathological observation of the endometrium. Our findings demonstrate that RHEC appears to have high potential for comprehensively improving various symptoms of menopause.

A Community-Based Cross-Sectional Study about the Quality of Life in Postmenopausal Women in Rural Puducherry

BACKGROUND

The aim of this study was to assess the quality of life (QOL) of postmenopausal women, in the rural areas of Puducherry and to find the associated factors.

MATERIALS AND METHODS

A cross-sectional study was done in the rural field practicing area of SLIMS, Puducherry. The sample size was 172 based on the previous study, and simple random sampling technique was used. The women who were receiving hormonal treatment, having chronic illness and those who refused to participate were excluded from the study. The sociodemographic information and menopause-specific QOL questionnaire were used, and data were analyzed using the SPSS 21.

RESULTS

In this study, mean age of the postmenopausal women was 61 ± 7.5 years, 42.4% belonged to socioeconomic status (SES) Class IV. The prevalence of one or more symptoms of vasomotor, psychological, and sexual domains were 23.8%, 87%, and 68%, respectively. We found an association between SES and both vasomotor and psychological symptoms. Furthermore, age and psychological symptoms were associated.

CONCLUSION

The menopause-related symptoms had a negative effect on the QOL of postmenopausal women. The study can help in creating awareness and also in helping in educating women for early identification of the frequent menopausal symptoms.

The relationship between hormone replacement therapy and periodontal disease in postmenopausal women: a cross-sectional study the Korea National Health and Nutrition Examination Survey from 2007 to 2012

Background

The purpose of this study was to investigate the relationship between hormone replacement therapy (HRT) and periodontal disease in postmenopausal women using data from the 4th and 5th Korea National Health and Nutrition Examination Survey (KNHANES).

Methods

The study included data from 5,482 postmenopausal women aged 45–74 years in the 2007–2012 KNHANES. The use of female HRT for at least one month was reclassified as HRT+/HRT-. The Community Periodontal Index of Treatment Needs (CPITN) was used to assess periodontal status. Propensity score matching (PSM) was used to control selection bias, and factors affecting education, family income, and age of menopause were used as covariates in PSM. A chi-square test was used to confirm the bivariate relationship between the variables. Binary logistic regression analysis was used to adjust for confounders (age, education, family income, body mass index, age of menopause, alcohol, smoking, dental clinic visits in the past one year, use of oral care products and frequency of tooth brushing per day).

Results

After adjusting for all covariates, HRT was associated with periodontal disease (OR: 0.79; 95% CI: 0.66–0.94). In particular, the relationship between HRT and periodontal disease was more evident in those with menopause under 45 years of age disease (OR: 0.55; 95% CI: 0.35–0.87).

Conclusions

The results of this study supported that it is important that hormone therapy be actively considered in the policy towards postmenopausal women. Especially, health programs such as hormone replacement therapy, non-smoking, and use of oral care products are needed for women who undergo premature menopause.

Quality of life in climacteric women assisted by primary health care

This cross-sectional study evaluated the quality of life and associated factors of climacteric women in Brazil using a random and representative sample of women assisted by primary care professionals. We investigated the variables using the Menopause-Specific Quality of Life Questionnaire, MENQOL, whose mean scores were compared using Mann–Whitney and Kruskal–Wallis tests according to the sample characteristics. The variables associated with the outcomes in univariate analyses with a p≤0.2 were jointly evaluated using multiple linear regression. In this study, 849 women ranging in age from 40 to 65 years were evaluated. The predictors of poor quality of life in the vasomotor domain were women with severe climacteric symptoms (p<0.001), increased Body Mass Index (BMI) (p = 0.006), sleep (p = 0.022), and postmenopausal (p<0.001) alterations. For the psychosocial domain, the associated variables were severe climacteric symptoms (p<0.001) and sleep alterations (p<0.001); for the physical domain, the associated variables were severe climacteric symptoms (p<0.001), increased BMI (p<0.001), sleep (p<0.001), and postmenopausal (p<0.001) alterations. Severe climacteric symptoms, low sleep quality, increased BMI, and postmenopausal status were factors that were more associated with impairments in quality of life. With the increase in life expectancy, we suggest that greater attention should be paid to women’s quality of life associated with climacteric symptoms.

Assessment of Quality of Life Based on Psychological, Somatovegetative, and Urogenital Health Problems among Postmenopausal Women in Urban Puducherry, South India: A Cross-Sectional Observational Study

Background:

An average Indian woman spends almost one-third of her lifespan in the postmenopausal phase enduring the consequences of hormonal decline. This can have a significant impact on quality of life (QOL). Hence, this study was conducted to assess the QOL and health problems among postmenopausal women in urban Puducherry, South India.

Methods:

A cross-sectional study was carried out among postmenopausal women attending urban primary health center between April and May 2017. Information about social, economic, and demographic characteristics was collected using a semi-structured questionnaire, and menopause rating scale was used to assess the QOL.

Results:

Among 204 participants, 55.4% belonged to elderly age group (≥60 years); 61.3% did not have any formal education; 55.9% of the participants were unemployed; 68.7% were widowed, separated, or divorced; 89.7% belonged to Hindu religion; and 42.2% belonged to lower socioeconomic class. Majority (78%) suffered from psychological problems followed by somatovegetative (62%) and urogenital problems (33%). The prevalence of poor QOL was 37.2% (95% confidence interval: 30.8%–44.0%). Participants belonging to Hindu religion (annual percentage rate [aPR]-4.14), in nuclear family (aPR-2.31), and with chronic comorbidity (aPR-5.52) and alcohol/tobacco users (aPR-6.03) had significantly higher risk of poor QOL.

Conclusion:

The current study found that more than one-third of the postmenopausal women in urban Puducherry have poor QOL with majority suffering from psychological problems. Hence, more focus needs to be given to this target population to achieve physical, social, and mental well-being among females.

The Roles of Menopausal-specific Quality of Life on Breast Cancer Screening Beliefs in Menopausal and Postmenopausal Women

Objectives

This study investigated the association between menopausal-specific quality of life (MENQOL) and breast cancer screening beliefs among Hong Kong Chinese menopausal and postmenopausal women.

Methods

A cross-sectional study was employed to collect data. The questionnaire was distributed to a convenience sample of 218 women aged above 45. The outcome variables were breast cancer screening beliefs and breast examination. Multiple regression analyses were conducted to test the effect of 4 domains in MENQOL (vasomotor, psycho-social, physical, and sexual symptom) and the health behaviors on the 2 outcome variables.

Results

This study found that the overall MENQOL scores (in particular psycho-social, and physical aspects) were significantly associated with positive attitudes toward health check-ups and better knowledge and perceptions in breast cancer. Regular exercise was also significantly related to breast examination.

Conclusions

MENQOL (especially psycho-social and physical domain) and regular exercise are important factors associated with breast cancer screening beliefs. The results of this study illuminate health care professionals to develop primary health care strategies to improve the quality of life of mid-life women.

Women's mid-life health in Low and Middle Income Countries: A comparative analysis of the timing and speed of health deterioration in six countries

Background

Mid-life is a neglected stage of women’s lives, particularly in Low and Middle Income Countries (LMICs). Birth injuries, menopause and manual labour can contribute to health problems in the mid-life.

Objectives

This study analyses the relationship between women’s health deterioration and age across socio-economic groups in 6 countries (China, Ghana, Mexico, Russia, South Africa and India).

Methods

Using constrained cubic splines, I analysed data from the WHO SAGE survey to examine age and wealth patterns in the onset of deterioration in objective proxies of ageing.

Results

Results show a clear pattern of deterioration in health in middle-aged women. Ageing processes differ dramatically between rich and poor strata within countries and between countries.

Discussion

This study clearly shows that the onset of ageing in women in LMICs begins in the early forties. The paper highlights the need to focus more on mid-life health of women, in particular poorer ones.

•

Mid-life is a neglected stage of women’s lives, particularly in Low and Middle Income Countries (LMICs).

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This study analyses the relationship between women’s health deterioration and age across socio-economic groups in 6 countries

•

The analyses reveal how physical – and to a lesser extent mental – declines in health occur early during the mid-life (35–65) in women.

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Inequalities in health deterioration are observed in all regions with poorer strata of the population experiencing an earlier onset of health deterioration.

•

Interventions to prevent, delay or reduce disability in older age should begin early in midlife.

Acupuncture and Neural Mechanism in the Management of Low Back Pain-An Update

Within the last 10 years, the percentage of low back pain (LBP) prevalence increased by 18%. The management and high cost of LBP put a tremendous burden on the healthcare system. Many risk factors have been identified, such as lifestyle, trauma, degeneration, postural impairment, and occupational related factors; however, as high as 95% of the cases of LBP are non-specific. Currently, LBP is treated pharmacologically. Approximately 25 to 30% of the patients develop serious side effects, such as drowsiness and drug addiction. Spinal surgery often does not result in a massive improvement of pain relief. Therefore, complementary approaches are being integrated into the rehabilitation programs. These include chiropractic therapy, physiotherapy, massage, exercise, herbal medicine and acupuncture. Acupuncture for LBP is one of the most commonly used non-pharmacological pain-relieving techniques. This is due to its low adverse effects and cost-effectiveness. Currently, many randomized controlled trials and clinical research studies have produced promising results. In this article, the causes and incidence of LBP on global health care are reviewed. The importance of treatment by acupuncture is considered. The efforts to reveal the link between acupuncture points and anatomical features and the neurological mechanisms that lead to acupuncture-induced analgesic effect are reviewed.

Determinants of Quality of Life and Satisfaction with Life in Women with Polycystic Ovary Syndrome

The purpose of the study was to assess the quality of life (QoL) and satisfaction with life (SwL) of women with polycystic ovary syndrome (PCOS) in comparison with those of healthy controls, and to identify and analyze factors determining QoL and SwL in women with PCOS. The cross-sectional study was performed between January and November 2016 in 504 women using health care services in Poland. The study group comprised women with PCOS, the control group women without PCOS. The study used a diagnostic survey with questionnaires. Research instruments included the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, the satisfaction with life scale (SWLS), and a standardized interview questionnaire comprising questions on the participants’ characteristics. Women with PCOS have lower QoL and SwL than healthy controls (p < 0.05). Factors affecting QoL in PCOS patients included socio-economic standing, time from PCOS diagnosis, BMI, age, and professional activity (p < 0.05). Factors affecting SwL in PCOS patients included socio-economic standing, having children, BMI, and time from PCOS diagnosis (p < 0.05). The higher the PCOS patients’ QoL, the higher their SwL (p < 0.05). Further studies are required, focusing both on PCOS and its etiology, and on its impact on the women diagnosed with the disease.

Danggwijagyaksan for climacteric syndrome in peri- and postmenopausal women with a blood-deficiency dominant pattern: study protocol for a randomized, double-blind, placebo-controlled pilot trial

Background

This study aims to explore the safety, efficacy, and feasibility of Danggwijagyaksan (DJS) for alleviating climacteric syndrome in peri- and postmenopausal women with a blood-deficiency dominant pattern.

Methods/design

This is a randomized, double-blind, placebo-controlled pilot clinical trial. A total of 34 women with climacteric syndrome who have signed informed consent forms will be registered in this study. Placebo or DJS will be randomly assigned to the participants in an equal proportion. The participants will visit the clinical trial center every 2 weeks and receive placebo or DJS granules. The treatment period is 4 weeks and the administration frequency is three times daily. Data will be collected from the participants at baseline, at week 5, and at week 9 after random allocation. The primary outcome measure will be the mean change in the Menopause Rating Scale from baseline to week 5. Secondary outcome measures will include the World Health Organization Quality of Life-BREF (WHOQOL-BREF) score, the Blood Deficiency Scoring System score, lean body mass, and blood tests, including serum follicle-stimulating hormone and estradiol concentration. To assess the safety of DJS, a laboratory test will be conducted before and after treatment and the participants will be asked about any occurrence of adverse events every visit. The recruitment rate, completion rate, and medication adherence will also be calculated, to assess feasibility.

Discussion

The findings of this study will provide the basis for a full-scale randomized controlled trial to confirm the safety and efficacy of DJS for the treatment of climacteric syndrome in peri- and postmenopausal women.

Trial registration

Clinical Research Information Service (CRIS), Republic of Korea, KCT0002387. Registered on 25 July 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-018-2443-8) contains supplementary material, which is available to authorized users.

Trajectories of mood and stress and relationships with protective factors during the transition to menopause: results using latent class growth modeling in a Canadian cohort

The menopause transition is characterized by significant hormonal changes that may predispose women to psychosocial maladjustment. Prospective studies to date have focused primarily on negative mood states and show equivocal findings. The primary goal of this study was to identify patterns of change with respect to positive and negative mood states (vigor, depression, tension, and stress) over a 5-year period in a cohort of women undergoing the transition to menopause. A secondary aim was to determine whether the identified trajectories were associated with menopause status as well as baseline health-related and psychological characteristics. This longitudinal study observed 102 healthy Canadian women who were premenopausal at baseline (age 47-55 years). Analyses consisted of latent class growth modeling. Mood states were predominantly normal and stable, raising doubts regarding the notion that psychosocial distress is a common and natural occurrence during the transition to menopause. Neither time spent in perimenopause nor BMI had a significant influence on levels of mood indicators. However, higher scores on body image, self-esteem, and general health perceptions were predictive of more positive psychological outcomes over the 5-year period. Targeting improvements in self-perceptions may promote a healthier psychological adjustment during this natural transitional period in a women's lifespan.

Severity and Frequency of Menopausal Symptoms in Middle Aged Women, Rasht, Iran

INTRODUCTION

Menopause is a natural event in women's life. Some studies have shown that, these symptoms can lead to low quality of life.

AIM

To identify the severity and frequency of menopausal symptoms in different stages of menopause, in a group of middle aged women.

MATERIALS AND METHODS

This cross-sectional study was conducted on 646 women aged 45-60 years in Rasht, Iran, who were included in the study by convenience sampling method. Menopause Rating Scale (MRS) was used to measure the severity of menopausal symptoms. Descriptive and analytical statistics by SPSS software version 19.0 was used for analysis.

RESULTS

Mean age of women was 50.7± 4.65 years. About half of the participants (49.2%) were postmenopausal. The remaining 18.1% (n=117) and 32.7% (n=211) were perimenopausal and premenopausal, respectively. The score of physical domain for menopause symptoms was higher in postmenopausal women. Joint and muscle problems were the most frequent symptoms in post and perimenopausal women. Also, total score for menopausal symptoms was more in postmenopausal group than other groups (p<0.001). Severe symptoms were seen only in three post-menopausal women and 55.2% of them had mild to moderate symptoms.

CONCLUSION

The menopause related symptoms differed based on the stage of menopause. Such studies are useful for creating awareness among women so that they can identify common menopausal symptoms and consequently may improve their quality of life.

Effect of Guizhifulingwan (Keishibukuryogan) on climacteric syndrome: study protocol for a randomized controlled pilot trial

Background

The aim of this study is to explore the efficacy of Guizhifulingwan (GFW) in the treatment of climacteric syndrome in women.

Methods/design

This is a single-center, randomized, placebo-controlled, parallel-group design pilot trial. Fifty participants with climacteric syndrome will be randomly allocated to the GFW or placebo group in a 1:1 ratio. The participants will be administered GFW or placebo granules three times a day for 4 weeks and will be followed up for a further 4 weeks. The primary outcome is the mean change in menopause rating scale score at 5 weeks after randomization. Secondary outcomes include the World Health Organization quality of life-BREF scores, degrees of upward movement of qi and lower abdominal resistance and tenderness, blood stasis pattern questionnaire scores, and results of blood tests including assays for lipid profile, high sensitivity C-reactive protein, follicle-stimulating hormone, and estradiol. The feasibility outcomes include recruitment and completion rates and adherence to medication.

Discussion

The results of this study will provide basic data for the design of a large-scale clinical trial for evaluating the efficacy of GFW in the treatment of climacteric syndrome in women.

Trial registration

Clinical Research Information Service (CRIS), Republic of Korea, KCT0002040. Registered on 5 September 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1877-8) contains supplementary material, which is available to authorized users.

Comparison between vaginal royal jelly and vaginal estrogen effects on quality of life and vaginal atrophy in postmenopausal women: a clinical trial study

Objective

This study was conducted to evaluate the therapeutic effects of vaginal royal jelly and vaginal estrogen on quality of life and vaginal atrophy in postmenopausal women.

Methods

This double-blind randomized controlled clinical trial was carried out at gynecology and obstetrics clinics of Hajar Hospital of Shahrekord University of Medical Sciences (Iran) from January 2013 to January 2014. The study was conducted on married postmenopausal women between 50 and 65 years old. Of 120 patients, 30 individuals were excluded based on the exclusion criteria, and 90 women were randomly distributed into three groups of 30 royal jelly vaginal cream 15%, vaginal Premarin, and placebo (lubricant), for three months. At the beginning and the end of the study, quality of life and vaginal cytology assay were evaluated. Data were analyzed by SPSS Version 11.

Results

Vaginal cream of royal jelly is significantly more effective than vaginal cream of Premarin and lubricant in improvement of quality of life in postmenopausal women (p<0.05). Moreover, Pap smear results showed that vaginal atrophy in vaginal Premarin group was lower than the other groups (p<0.001), and there was no significant difference between lubricant and royal jelly groups (p=0.89).

Conclusion

Administration of vaginal royal jelly was effective in quality-of-life improvement of postmenopausal women. Given to the various properties of royal jelly and its effectiveness on quality of life and vaginal atrophy in postmenopausal women, further studies are recommended for using =royal jelly in improving menopausal symptoms.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT code: 2014112220043n1.

Funding

Shahrekord University of Medical Sciences supported this research (project no. 1440).

Quality of life among menopausal women: A community-based study in a rural area of West Bengal

Introduction:

During menopausal transition, there is a lot of fluctuation in the hormone levels making the peri and postmenopausal women susceptible to various mental and physical disorders. There is considerably lack of awareness about the effects of the menopausal symptoms in women in India. Studies on issues relating to menopause, especially among rural women, are also lacking. With this background, the current study was carried out in a rural area of West Bengal with the objective to assess the quality of life (QOL) of peri-menopausal women.

Methodology:

The study was carried out among 100 peri and postmenopausal women (40–60 years) in Dearah village of West Bengal which is the rural field practice area of All India Institute of Hygiene and Public Health during February–March 2014. The questionnaire used as study tool had two parts - Part 1: Sociodemographic characteristics. Part 2: About QOL due to menopausal symptoms based on four domains (vasomotor, psychosocial, physical, and sexual) using the 29-item Menopause-Specific Quality of Life Questionnaire.

Results:

Occurrence of vasomotor symptoms was average with 60% of them reporting hot flushes and 47% sweating. Most prevalent psychosocial symptoms reported were feeling of anxiety and nervousness (94%) and overall depression (88%). Physical symptoms were quite varying in occurrence with some symptoms such as feeling tired or worn out, decrease in physical strength and lack of energy occurring in 93% of the women to only 5% suffering from growth of facial hair. Overall sexual changes were reported among 49% who reported of avoiding intimacy with a partner and 26% complained of vaginal dryness.

Conclusions:

The results support that menopause causes both physical and psychiatric problems. Education, creating awareness and providing suitable intervention to improve their QOL are important which should be imparted to menopausal women at both individual and community level.

Health Promoting Lifestyle Behaviors in Menopausal Women: A Cross-Sectional Study

BACKGROUND

Determining health promoting lifestyle behaviors of age-specific groups of women provides valuable information for designing health promotion intervention programs. Hence the present study was conducted to assess health promoting lifestyle behaviors in menopausal women.

METHODS

The present descriptive cross-sectional study examined health promoting lifestyle behaviors in 400 menopausal women admitted to health care centers in Neka city-north of Iran-from March 2015 to July 2015. Health promoting lifestyle behaviors were evaluated using a demographic characteristics form and the Health Promoting Lifestyle Profile II (HPLP II) through simple convenience sampling. Data were analyzed in SPSS version 18 using descriptive and inferential statistics at the significance level of P<0.05.

RESULTS

The mean score of participants' health promoting lifestyle behaviors was 136.43±19.61, ranging from 88 to 194. The logistic regression test revealed women's health promoting lifestyle behaviors to be significantly related to their place of residence (P=0.009, odds ratio=1.73) and their spouse's level of education (P=0.027, odds ratio=0.58). The Pearson correlation test showed significant relationships between mean score of the six sub-scale of health promoting lifestyle behaviors with each other (P<0.001).

CONCLUSION

These findings have implications for addressing the role of men to promote health promoting lifestyle behaviors among rural menopausal women.

Comparison of the Effects of Vaginal Royal Jelly and Vaginal Estrogen on Quality of Life, Sexual and Urinary Function in Postmenopausal Women

INTRODUCTION

Several causes can disturb the quality of life in postmenopausal women. Stress, urinary incontinence is one of the factors that can influence the quality of life of women, since they evade social activities and limit their behavior. Vulvovaginal disorders adversely impacts sexual action, psychosocial health, and partner relationships.

AIM

The aim of this study was to examine the therapeutic properties of vaginal cream of royal jelly and estrogen on quality of life, sexual and urinary problems in postmenopausal women.

MATERIALS AND METHODS

This study was a randomized controlled clinical trial that was done on 90 married postmenopausal women 50 to 65-year-old. A total of 90 women were randomly distributed to three groups and were treated with vaginal cream of royal jelly 15%, lubricant, and conjugated estrogens for three months. Before and after intervention, quality of life and vaginal cytology were evaluated. Data was analysed by SPSS 16 using ANOVA and Tukey tests.

RESULTS

The results expressed that vaginal royal jelly is considerably more effective than conjugated estrogens and lubricant in the improvement of quality of life, sexual and urinary function in postmenopausal women (p<0.05). Results of Pap smear showed that improvement of vaginal atrophy in conjugated estrogens group was better than other groups (p<0.001), and there was no significant difference between lubricant and royal jelly groups (p=0.89).

CONCLUSION

The effectiveness of vaginal royal jelly in treatment of sexual and urinary problems of postmenopausal women is related to its estrogenic properties and could be suitable in promotion of life quality in postmenopausal women.

Low back pain in women before and after menopause

Low back pain is a massive problem in modern population, both in social and economic terms. It affects large numbers of women, especially those aged 45-60. Going through a perimenopausal period is associated with many symptoms, including low back pain. This paper is a review of published research on the association between the perimenopausal age and low back pain. PubMed databases were investigated. After the search was narrowed to "menopausal status, back pain", 35 studies were found. Seven studies, which suited our area of research best, were thoroughly analyzed. All studies show increased pain when women enter this period of their life. There is no agreement among researchers regarding which stage of menopause is the most burdensome. Examples of possible treatments and physiotherapeutic methods targeting low back pain are also presented. Physiotherapeutic procedures used to treat low back pain include exercises in safe positions, balance exercises, manual therapy, massage and physical measures.

Assessment of Questionnaire Measuring Quality of Life in Menopausal Women: A Systematic Review

Menopause is a natural part of the aging process in women and is defined as occurring 12 months after the last menstrual period marking the end of menstrual cycles. Menopause has a negative impact on the quality of life (QoL). Various generic and specific questionnaires have been used for assessing different dimensions of QoL in menopausal women. The purpose of this systematic review was to identify those general and specific instruments, and to determine the factors that affect QoL in menopausal women. We assessed eight specific and three general tools and found that some general and specific instruments, such as the 36-item short form (SF-36) and the Menopause Specific Quality of Life Questionnaire (MENQOL), were mostly used for assessment. The specific tools available were diverse. Employment status and a high educational level in menopausal women were considered to be protective factors in improving QoL. Identification of predicting factors of QoL, such as body mass index, race, age, duration of menopause, and social and occupational variables can help to improve the QoL of these women allowing planning of psychological consultations and practical interventions.

Menopausal symptoms and its effect on quality of life in urban versus rural women: A cross-sectional study

Aim and Objective:

To analyze the menopause-related symptoms and its impact on quality of life in post-menopausal women from urban and rural area.

Materials and Methods:

A cross-sectional 1-year study was carried among women of urban (n = 490) and rural (n = 380) areas, attending the outpatient department in the urban area and a house-to-house survey in rural areas, by interviews with the help of a pretested semi-structured standard questionnaire. For assessment of the menopausal symptoms menopause rating scale (MRS) and for quality of life, World Health Organization Quality of Life Scale (WHO QOL-BREF) questionnaire was used.

Results:

There was a significant difference between the MRS total scores of the urban (14.67 ± 6.64) and rural (16.08 ± 7.65) group. The somatic, psychological, and urogenital symptoms were high in rural women than in urban women. The results were not significant for urogenital subscale. The mean raw scores of physical health, psychological, social relationships, and environmental domains was more in urban than in rural women. The mean transformed scores (4-20) of physical health, psychological, social relationships, and environmental domains was more in urban than in rural women. The mean transformed scores (0-100) including the physical health, psychological, social relationships, and environmental domains was more in urban than in rural women. The result was not significant for physical health.

Conclusion:

The high proportions and the scores of MRS were observed in both rural and the urban women. The severity of symptoms was found more distressing for rural women. The quality of life in urban society was average and better than in rural women.

The influence of climacteric symptoms on women's lives and activities

In the present study, we performed an analysis of the influence of climacteric symptoms on women's lives and activities, i.e. their quality of life (QoL). The study was performed between October 2011 and February 2012. It included 148 women aged 44-62. The study used a diagnostic survey with questionnaires. The research instrument was the Blatt-Kupperman index. The respondents were asked to complete a questionnaire on socio-demographic data, quality of life, and the influence of climacteric symptoms on life and its various aspects. The respondents experiencing moderate or severe climacteric symptoms also had stronger feelings of failure (p = 0.005), feeling that opportunities are still available (p = 0.002), of losing their youth and beauty (p < 0.0001), compared to those who had slight or no symptoms. The intensity of climacteric symptoms significantly affects women's lives and activities, i.e., their QoL. The reported intensity of climacteric symptoms is influenced by the respondents' education, residence, marital status and professional activity. The more severe the climacteric symptoms, the lower the women's quality of life, as evidenced for example by the feeling of failure and of losing one's youth, beauty and opportunities.

Effect of physical exercise on changes in activities of creatine kinase, cytochrome c oxidase and ATP levels caused by ovariectomy

The reduction in the secretion of ovarian hormones, principally estrogen, is a consequence of menopause. Estrogens act primarily as female sex hormones, but also exert effects on different physiological systems including the central nervous system. The treatment normally used to reduce the symptoms of menopause is the hormone therapy, which seems to be effective in treating symptoms, but it may be responsible for adverse effects. Based on this, there is an increasing demand for alternative therapies that minimize signs and symptoms of menopause. In the present study we investigated the effect of ovariectomy and/or physical exercise on the activities of energy metabolism enzymes, such as creatine kinase (cytosolic and mitochondrial fractions), pyruvate kinase, succinate dehydrogenase, complex II, cytochrome c oxidase, as well as on ATP levels in the hippocampus of adult rats. Adult female Wistar rats with 90 days of age were subjected to ovariectomy (an animal model widely used to mimic the postmenopausal changes). Thirty days after the procedure, the rats were submitted to the exercise protocol, which was performed three times a week for 30 days. Twelve hours after the last training session, the rats were decapitated for subsequent biochemical analyzes. Results showed that ovariectomy did not affect the activities of pyruvate kinase, succinate dehydrogenase and complex II, but decreased the activities of creatine kinase (cytosolic and mitochondrial fractions) and cytochrome c oxidase. ATP levels were also reduced. Exercise did not produce the expected results since it was only able to partially reverse the activity of creatine kinase cytosolic fraction. The results of this study suggest that estrogen deficiency, which occurs as a result of ovariectomy, affects generation systems and energy homeostasis, reducing ATP levels in hippocampus of adult female rats.

A measurement-specific quality-of-life satisfaction during premenopause, perimenopause and postmenopause in Arabian Qatari women

OBJECTIVE

The aim of this study was to use an instrument, the menopause-specific quality-of-life satisfaction in the state of Qatar for the premenopausal, menopause and postmenopausal period.

DESIGN

A cross-sectional descriptive study was used to generate menopause symptoms experienced by Arabian Gulf women. Measurement-specific quality-of-life satisfaction questionnaires and face-to-face interviews were performed.

SETTING

Primary Health Care (PHC) Centers in Qatar.

MATERIALS AND METHODS

A multistage sampling design was used and a representative sample of 1,500 women aged 40-60 years were included during July 2012 and November 2013, and 1,158 women agreed to participate (77.2%) and responded to the study.

RESULTS

The mean age and standard deviation of the subjects was 50.9 ± 6.1. The median age of natural menopause in the present study was 49 years [mean and standard deviation 49.9 ± 2.7]. The rate of consanguineous marriages in the sample was found to be 30.3%. There were statistically significance differences between menopausal stages with regard to ethnicity, education level, occupation, type of housing condition, and consanguinity. There were statistically significance differences between menopausal stages concerning BMI groups, Systolic BP, Diastolic BP, physical activity, parity, and sheesha smoking habits. Meanwhile, the present study revealed that the most common disease was found to be diabetes mellitus (11.4%), followed by hypertension (6.6%), asthma (5.6%) and CHD (2.5%), and the majority of subjects (69.5%) had no specific disease. The most frequent symptom was aches in the back and neck (49.2%), night sweat (37.2%), low backache (35.7%), feeling nervous (35.4%) followed by aches in the muscles/joints (34.6%), hot flashes (33.3%), decreased social activities (28.3%), decreased leisure activities (47.6%), difficulty sleeping (28.9%), mood swings (25.4%), and decreased concentration (28.3%), sexual activity (24.1%) and total energy level (26.7%). The lowest reported symptoms were facial hair at 16.1% followed by dissatisfied with my personal life at 18.1%. Cronbach's alpha scores, measuring the internal consistency of questions in each domain for physical, vasomotor, psychosocial and sexual were 0.883, 0.853, 0.697 and 0.805, respectively. The Spearman's rank correlation coefficient between domains indicated that there is highly significant concordance between the four domains (P < 0.001).

CONCLUSION

A large number of factors were associated with experiencing menopausal symptoms and which had negative effects on the quality of life among Arabian women. The current study showed that climacteric symptom in menopausal Arab women is less than Western women, which may be influenced by socio-economic, genetics, environment and parity.

Epidemiology of the symptoms of menopause - an intercontinental review

Introduction

The age of menopause is a time of many changes in the psychophysical-social functioning of women, with reduced ovarian hormonal activity and estrogen levels. The most common, troublesome symptoms of menopause age include depressive disorders, sleep disorders, sexual dysfunction, discomfort associated with muscle pain, joint aches, osteoporosis and characteristic hot flashes.

Aim of the study

Aim of the study is to determine and compare the rate of menopausal symptoms among women living in continents of both Americas, Africa, Australia and Eurasia.

Material and methods

The results of this work were obtained in 2014 on the basis of the data from a review of the 64 most important studies using the PubMed database. Research published in the period 2000-2014, from Africa, both Americas, Australia and Eurasia, were taken into account.

Results

The prevalence of menopausal symptoms in African women is disconcertingly high. Women from South America complain about occurrence of depressive, sexual dysfunctions and discomfort associated with muscle pain and joint aches. Symptoms most reported by women in the United States are pains associated with muscles and joints. Women in Australia suffer mainly due to vasomotor symptoms and sexual dysfunction, while in the group of women surveyed in Asia there is observed an alarming increase in the proportion of women reporting depressive disorders. In Europe there was a much greater incidence of sleep disorders and depressive disorders.

Conclusions

Women around the world suffer from ailments characteristic for the menopausal period regardless of ethnic origin, skin color or socio-demographic factors.

Menopausal symptoms of postmenopausal women in a rural community of Delhi, India: A cross-sectional study

Background:

There is very little data on the consequence of menopause on women in South East Asia region, especially from rural India. Importance is always given to reproductive health from menarche to menopause. Menopausal health demands priority in Indian scenario due to rising population of postmenopausal women.

Objectives:

The aim was to determine the mean age at attaining menopause and the prevalence of various self-reported menopausal symptoms complained by postmenopausal women (40-54 years). Furthermore, to determine the prevalence of anxiety and depression among postmenopausal women.

Materials and Methods:

A cross-sectional study was conducted in a rural area of New Delhi among 252 postmenopausal women from October 2011 to March 2013. A pretested, self-designed, semi structured, interview based, oral questionnaire was used. The Statistical Package for Social Sciences software Version 21.0 (SPSS) was used for analyses.

Results:

The mean age at attaining menopause was 46.24 (Standard Deviation = 3.38) years. Only 4 (1.6%) postmenopausal women had premature menopause. A total of 225 (89.3%) postmenopausal women experienced at least one or more menopausal symptom(s). The most common complaints of postmenopausal women were sleep disturbances (62.7%), muscle or joint pain (59.1%), hot flushes (46.4%) and night sweats (45.6%). A total of 32.1% (n=81) postmenopausal women suffered from depression and 21.0% (n=53) postmenopausal women suffered from anxiety.

Conclusion:

It is necessary to critically introspect health needs of postmenopausal women and specific components can be incorporated in the national health programs.

Relationship between menopause and health-related quality of life in middle-aged Chinese women: a cross-sectional study

Background

Chinese menopausal women comprise a large population and the women in it experience menopausal symptoms in many different ways. Their health related quality of life (HRQOL) is not particularly well studied. Our study intends to evaluate the influence of menopause on HRQOL and explore other risk factors for HRQOL in rural China.

Methods

An interview study was conducted from June to August 2010 in Beijing based on cross-sectional design. 1,351 women aged 40–59 were included in the study. HRQOL was measured using the EuroQol Group’s 5-domain (EQ5D) questionnaire. Comparison of HRQOL measures (EQ5D index and EQ5D-VAS scores) was done between different menopausal groups. Logistic regression and multiple regression analysis were performed to adjust potential confounders and explore other risk factors for health problems and HRQOL measures.

Results

Postmenopausal women who had menopause for 2–5 years (+1b stage) were more likely to suffer mobility problems (OR = 1.835, p = 0.008) after multiple adjustment. Menopause was also related to impaired EQ5D index and EQ5D-VAS scores after adjustment for age. Among menopausal groups categorized by menopausal duration, a consistent decrement in EQ5D index and EQ5D-VAS scores, that is, worsening HRQOL, was observed (p < 0.05). Multiple regression analysis revealed low education level and physical activity were associated with EQ5D index (β = -0.080, p = 0.003, and β = 0.056, p = 0.040, respectively). Cigarette smoking and chronic disease were associated with EQ5D index (β = -0.135, p < 0.001 and β = -0.104, p < 0.001, respectively) and EQ5D-VAS (β = -0.057, P = 0.034 and β = -0.214, p < 0.001, respectively).

Conclusions

Reduction in physical function was found within the first five years after menopause. Worsening EQ5D index and EQ5D-VAS scores were related to menopause. Education level, physical activity, cigarette smoking, and chronic disease history were associated with HRQOL in middle aged Chinese rural women.