April, 2008

Knowledge and attitude towards menopause and Hormone Replacement Therapy (HRT) among postmenopausal women

  Humaira Saeed Malik  ( Department of Gynaeology / Obstetrics, Jinnah Medical College Hospital Karachi )

Introduction: To determine the knowledge and attitude towards menopause and Hormone Replacement Therapy (HRT) among postmenopausal women.
Method: A descriptive cross sectional study based on sample of convenience was conducted at outpatient services of Jinnah Medical College Hospital Karachi from 1st January 2005 to 30th April 2005. One hundred and two postmenopausal women who came to outpatient department of Jinnah Medical College Hospital Karachi as a patient or as an attendant were interviewed after taking verbal consent. Sociodemographic characteristics, knowledge and attitude towards menopause and HRT were collected through a structured pretested questionnaire.
Results:  The mean age of respondents was 55.1 ± 10 years (range 40 - 75 years). The mean age at menopause was 47.4 ± 3.3 years. Majority of respondents belonged to poor socioeconomic class (75.5%) and 62 (60.8%) had received no formal education. Ninety seven percent of women had heard about menopause and 29.4% were aware of the symptoms. Four (3.92%) knew the long term implications of menopause. Out of 102, only 02 (1.96%) respondents were aware of HRT. Most of respondents (94%) did not consider menopause to be a medical condition but a normal transition. Majority of respondents had positive (47%) or Neutral (39.2%) attitude towards menopause. Thirty six (35.29%) respondents were not sexually active. Decrease libido and frequency was reported by 33 (32.3%) respondents while 25(24.5%) reported no change.
Conclusion: Majority of women lacked sufficient knowledge on menopause and HRT. Women's attitude towards menopause showed that majority considered it a natural event and not a medical condition (JPMA 58:164;2008).

Menopause is a physiological event occurring with ovarian failure and marks the end of women's reproductive life.1 The average age of menopause is 51 years.1 In 1960, the world population of women aged over 60 was below 250 million, but it is estimated that in the year 2030, 1.2 billion will be peri or postmenopausal and that this total will increase by 4.7 million a year.2 The average woman in the developed world can now expect to spend approximately one third of her life in postmenopausal state.3 Because of these predicted changes in population structure, physicians are beginning to see that menopause is not a negligible phenomenon but a major public health problem.2
Attitudes, perceptions and expectations are part of the psychosocial phenomenon surrounding menopause.4 Women in midlife and health professionals believe that attitude plays a role in experience of menopause.5 Hormonal changes at menopause are associated with numerous physical and psychological symptoms like vasomotor symptoms, sleep disturbances, mood alteration, depression, urinary tract infection, vaginal atrophy and increased health risks for several  chronic disorders including osteoporosis cardiovascular disease and loss of cognitive function. Menopausal symptoms are found to be less common in societies where menopause is viewed as a positive rather than negative event.4 The Massachusetts women health study did a longitudinal study on more than 2000 women between 45 and 55 years. This study showed that negative attitude towards menopause leads to less favourable mode of climacteric.6 This cultural aspect of menopausal symptoms has been discussed in a number of studies among Asian women including Japanese and Chinese population.1
It is well established that HRT is an effective means of treating postmenopausal symptoms and preventing long term complications such as osteoporosis.7-10 The HRT usage rate is low largely because majority remain poorly informed about this therapy.11,12
The aim of this study was to determine the knowledge and attitude towards menopause and HRT among postmenopausal women.
Subjects and Methods
A cross sectional study was conducted from 1st February 2005 to 30th April 2005 at Jinnah Medical College Hospital, Karachi. A structured questionnaire was used which was pretested in 15 respondents. A convenient sample of postmenopausal women coming to outpatient services of hospital as a patient or as an attendant was used. A total of one hundred and ten postmenopausal women with menopause occurring either naturally or surgically induced, were approached for interview after taking verbal consent. The sociodemographic variables included the present age, parity, education level, marital status, social status, age of menarche and age at menopause. Age was measured in years. Education was divided in five levels Nil, Primary, Middle, Matric and Graduate. Marital status was coded in four categories single, married, widowed and divorced. Respondents were divided in poor, lower middle, upper middle if family income was less than Rs. 5000 per month, up to Rs. 15000 per month or more than Rs. 15000 per month respectively.
The respondents were asked if they had ever heard or knew about menopause. Questionnaire was in Urdu language and respondents were asked if they had the knowledge on menopause at the time when their periods stopped. Respondents were further questioned on the knowledge of menopausal symptoms, long term implications and different methods of treatment of menopause. Respondent's attitude towards menopause were asked and enquiry was made regarding their opinion about this life event whether it was positive, negative or neutral. Furthermore, they were asked if they considered menopause as a medical condition or a normal transition. Respondents were asked about their sexual relationships. All respondents were asked if they had ever heard of HRT. All respondents who had heard about HRT were additionally questioned about the source of information with the benefits and risks of its use. Data collected was analyzed utilizing statistical package for social sciences (SPSS) version10.

Complete data from One hundred and two postmenopausal women were obtained. Eight questionnaires were not completed hence not used for analysis.  The sociodemographic characteristics of the study population are shown in Table.
Mean age of respondents was 55.1 ± 10.1 years, with a range of 40 to75 years. The mean age of menarche was 12.79 ± 0.79 years. The mean age at menopause was 47.4 ± 3.3 years. Majority of women were married (82.3%). Parity of the respondents ranged from 0 - 13 and 72 (70.5%) had 5 or more children. Only two respondents were nulliparous. Majority of respondents had received no formal education (60.8%) and belonged to poor socioeconomic group (75.5%).
Regarding their awareness of menopause, 97 (95%) women had previously heard of menopause. Most of these women had heard about it from elders in family and friends. Thirty (29.4%) respondents had some knowledge of menopausal symptoms. Only 4 (3.92%) respondents were aware of long term implications of menopause. Out of 102, only 2 (1.96%) respondents knew about Hormone replacement therapy and source of their knowledge was their health professionals. Majority of women considered menopause as a positive (47%) or neutral change (39.2%) and indicated that it did not affect their relationship with their spouse and children. Most women (94%) did not perceive menopause to be a medical condition but a natural transition. Thirty-six (35.29%) respondents were not sexually active. Decrease libido and frequency was reported by 33 (32.3%) respondents while 25(24.5%) reported no change. Out of one hundred and two only four (3.92%) respondents were aware of treatment of menopause. Only one respondent realized that HRT could relieve menopausal symptoms and prevent long term health risks, while the rest had no knowledge of this aspect.

Menopause marks a time of dramatic hormonal and often social change for women.2 As life expectancy is rising, more women are exposed to the potential long term consequences of menopause. HRT can have significant benefits in postmenopausal women, yet rates of HRT use are low. Knowledge of menopause is a key predictor of HRT use. The attitudes of women to menopause are strongly influenced by social, cultural and economic settings in which they live and may also reflect the differences in modes of treatment for or perceptions of its symptoms.1 Menopausal symptoms are observed in all countries of the world but prevalence varies from society to society. Hot flushes and night sweating is the commonest climacteric symptom experienced in Caucasian population.13 In Netherlands, Oldehave et al found that up to 85% of perimenopausal women experienced such complaints.14 Lock et al however reported that such complaints hardly existed in Japanese women.15 Majority (95%) of women had heard about menopause .This is comparable to other studies,16-18 but few females (29.7%) had knowledge about symptoms and long-term health risks (3.9%).
Attitudes towards menopause and aging differed across ethnic groups, with African women being the most positive and Chinese American and Japanese American women least positive.19 In this survey majority of women expressed either positive (47%) or neutral (39.2%) attitude towards menopause signalling freedom from cyclical bleeding and independence. This finding is similar to the findings of other studies.17,18,20 This is in contrast to a study on Hispanic women who regret when their periods stop.12 Another survey carried out with an aim of understanding views and values of Asian women of Indian origin living in UK, related to menopause and HRT. Of all the women surveyed, 33% felt happy and 46% felt afraid of  menopause.21 In this study, majority of respondents (94%) did not perceive menopause to be a medical condition but a part of the natural aging. The same findings have been observed in other studies.22,23
Majority of respondents in the study had never heard of HRT. Lack of information about HRT is the most important reason of not using it. This is comparable to findings in other studies.18,20 Lack of Knowledge being greatest in less educated, older and poor socioeconomic class. This finding is consistent with results of other studies.9,4 Well educated women may be more likely to read articles about HRT, have more substantive discussions with physicians about their personal benefits and risks of HRT use and thus seek treatment.24 Lack of awareness about long-term implications of menopause among women may result in low HRT usage rate. Another reason for not having the knowledge on HRT was that women were not advised by their health care provider to use HRT. About 75% of nonusers of HRT would consider HRT if so recommended by their doctors.6
The benefit and risk profile of HRT varies greatly depending on the timing of its initiation, the kind of estrogen or progesterone used and their route of administration and dosing. Therefore in deciding to go for HRT, the risks and benefits should be weighed carefully in individual patients and informed consent obtained for its administration.25

The study revealed a general lack of knowledge about menopause and HRT. Women's attitude towards menopause ranged from positive to neutral. Better education about menopause from media sources and healthcare providers is needed regarding the long-term risks associated with menopause and pros and cons of HRT so that women can take informed health decisions, which may results in improvement in quality of life.

The statistical help of Dr Sanower Ali Naqvi, Department of Community health sciences, Jinnah Medical College Hospital Karachi is gratefully acknowledged.

1. Pam HA, Wu MH, Hsu CC, Yao BL, Huang KE. The perception of menopause among women in Taiwan. Maturitas 2002; 41: 269-74.
2. Jin Yong Lee, Chang Suk Suh. The attitudes of postmenopausal women towards hormone replacement therapy(HRT) and effects of HRT on lipid profiles. Proceedings of the first consensus meeting on menopause in East Asian region,  1997; May 26-30, Geneva, Switzerland. 
3. Avis NE. Women's perceptions of menopause. Euro Menopause J 1996;3:80-4.
4. Cowan G, Warren LW, Young JL. Medical perceptions of menopausal symptoms. Psychol women 1985; 9: 3-14.
5. Avis NE, Mckinly SM .A longitudinal analysis of women's attitudes towards the menopause, results from the Massachusetts Women Health Study 1991; 13:65-79.
6.  Shafi S,  Samad Z, Syed S, Sharif A, Khan MA, Nehal US, et al. Hormone replacement therapy menopause with a better future-A survey of views on hormone replacement therapy (HRT). J Pak Med Assoc 2001; 51: 450-3.
7. Obel EB, Munk Jensen N, Svenstrup B, Bennet P, Micic S, Henrik -Nielsen R, et al. A two year double blind controlled study of the clinical effect of combined and sequential postmenopausal replacement therapy and steroid metabolism during treatment. Maturitas.1993; 16:13-21.
8. Ettinger B, Genant HK, Cann CE. Long term estrogen replacement therapy preventing bone loss and fracture. Ann Int Med. 1985; 102: 319-24.
9. Maharaj NR, Gangaram R, Moodley J. The Menopause, hormone replacement therapy and informed consent: are women in an under resourced country adequately aware? J Obstet Gynecol 2007; 27: 300-4.
10. Horner E, Fleming J, Studd J. A study of women on long-term hormone replacement therapy and their attitude to suggested cessation. Climacteric 2006; 9: 459-63.
11. Lam PM, Leung TN, Haines C, Chung TK.. Climacteric symptoms ad knowledge about HRT among Hong Kong Chinese Women Aged 40- 60 Years .Maturitas 2003; 45: 99-107.
12. Nir-Caein R, Nahum R, Yogev Y, Rosenfeld J, Fisher M, Kaplan B. Ethnicity and attitude towards menopause and hormone replacement therapy in Northern Israel. Clin Exp Obstet Gynecol 2002; 29: 91-4.
13. Bosworth HB, Bastian LA, Kuchibhatia MN, Steffens DC, McBride CM, Skinner CS, et al. Depressive symptoms, menopausal status and climacteric symptoms in women at midlife. Psychosom Med 2001;63:603-8.
14. Oldenhave A, Jaszmann LJ, Haspels AA, Everaerd WT. Impact of climacteric on wellbeing: a survey based on 5213 women 39 to 60 years old. Am J Obstet Gynecol 1993;168:772-80.
15. Lock M, KauFert P, Gilbert P. Cultural construction of the menopausal syndrome: the Japanese case. Maturitas 1988; 10:317-32.
16. Pan HA, Wu MH, Hsu CC, Yao BL, Huang KE. The perception of menopause among women in Taiwan Maturitas 2002; 41: 269-74.
17. Yahya S, Rehan N. Perceptions of menopause among rural women of Lahore. J Coll Physician Surg Pak 2003,.13: 252-4.
18. Mazhar SB, Gul-e-Erum. Knowledge and attitude of older women towards menopause. J Coll Physician Surg Pak 2003; 13: 621-24.
19. Sommer B, Avis N, Meyer P, Ory M, Madden T, Kagawa-Singer M, et al. Attitudes Towards Menopause and Aging Across Ethnic/Racial Groups. Psychom Med 1999; 61: 868-75.
20. Kaufert P, Boggs P P, Ettinger B, Woods N F, Utian WH. Women and menopause: beliefs, attitudes and behavior. The North American Menopause Society 1997. Menopause Survey. Menopause 1998; 5: 197-202.
21. Sethi K, Pitkin J. British-Asian women's views on and attitudes towards menopause and hormone replacement therapy.Climacteric 2000; 3: 248-53.
22. Carolan M. Menopause: Irish women's voices. J Obstet Gynecol Neonatal Nurs 2000; 29: 397-404.
23. Adekunle AO, Fawole AO, Okunlola A. Perceptions and attitudes of Nigerian women about the menopause. J Obstet Gynaecol 2000; 20: 525-9.
24. Rachon D, Zdrojewski T, Suchecka-Rachon K, Szpakowski P, Bandosz P, Manikowski A, et al .Knowledge and use of hormone replacement therapy among polish women: estimates from a nationally representative study-HORTPOL 2002 Maturitas 2004;.47: 31-3.
25. Ohta H. Hormone replacement Up-to-date. Menopause in women and hormone replacement therapy (HRT). Indications for HRT in postmenopausal women. Clin calcium. 2007; 17: 1315-24.

News & Events

Shahid beheshti University of Medical sciences, Tehran-Iran Otology/Neurotology Fellowship Program

The Division of Otology/Neurotology is currently seeking candidates for the one-year clinical fellowship position in Otology/Neurotology/Skull Base Surgery.

Requirements for Appointment:

  • Board eligible/Board certified Otolaryngologist, International applicants will be considered
  • Ability to begin October 1, 2013
  • Position of Clinical Fellow
  • 4 weeks of vacation
  • Availability and support to present research at national meetings
  • A letter of interest, curriculum vitae, and two letters of recommendation should be sent to:
Ali Eftekharian, MD
Director, Neurotology Fellowship Program
Shahid beheshti University of Medical sciences, Department of Otolaryngology / Head and Neck Surgery Tehran, Iran
Phone: 0098-21-55405315 Fax: 0098-21-55416170
Email: alishko@gmail.com