Seyhan Hidiroglu ( Department of Public Health, School of Medicine, Marmara University, Istanbul Turkey. )
Ozlem Tanriover ( Department of Family Medicine School of Medicine, Yeditepe University, Istanbul Turkey. )
Pinar Ay ( Department of Public Health, School of Medicine, Marmara University, Istanbul Turkey. )
Melda Karavus ( Department of Public Health, School of Medicine, Marmara University, Istanbul Turkey. )
Objective: To look at menopause from men\'s point of view and to provide a better understanding of this phase to improve the care delivered to menopausal women.
Methods: The study was conducted at the health centre of a single district of Istanbul, from April 2013 to June 2013, which serves as the research and training area of the Marmara University and which receives migrations from mainly southern and eastern regions of Turkey. The study sample included 33 married men. Qualitative in-depth interviews were performed individually and main themes were noted down for analysis.
Results: The age range of the study population was 40-77 years. The subjects lacked basic knowledge about both menstruation and menopause. Most of the participants defined menopause as loss of fecundity, increased weight, and loss of beauty. The most important concern voiced was men\'s own sexual life. None of the men had heard about treatment modalities available for menopause.
Conclusion: Interventions are needed to increase men\'s awareness regarding menopause in order to help these men to be able to better support their spouses so that they can both have a smooth transition into postmenopausal years.
Keywords: Men, Menopause, Qualitative, Turkish, Perceptions, In-depth. (JPMA 64: 1031; 2014).
Subjects and Methods
The study was conducted at the health centre of a single district of Istanbul, from April 2013 to June 2013, which serves as the research and training area of the Marmara University and which receives migrations from mainly southern and eastern regions of Turkey. The study sample included relatively older married men. One of the researchers visited the local family health centre and approached men who had come there for healthcare assistance. Those who agreed to participate were then asked to bring their peers along, and, as such, the subjects were located by snowball sampling method.
In the initial phase, a focus group discussion was held with 6 participants. One of the researchers acted as the facilitator and the other as the observer. The facilitator was a female. During the session it was observed that men were reluctant to answer the questions freely. When they were asked about what was bothering them, the participants responded that they felt shy talking about their wives in front of other men in public and that they preferred to talk to a male researcher rather than in the presence of a female. The method was then changed from a focus group to an individual in-depth interview with a male researcher. A semi-structured guide was used for the purpose to ensure uniformity.
All participants were administered a mini-questionnaire prior to the interview for taking down the essential socio-demographic data.
The interviews were performed at the local family health centre. There was no table in the room and the interviewer and the interviewee sat on similar office chairs, at the same level, looking face to face. The interviews lasted 20-30 min. After obtaining permission of the participants, a sound recording device was used. After each session, the interviewers took notes on what they observed and then the tapes were transcribed verbatim within 48 hours of the interviews. Key themes were identified and a coding frame was developed. The Word processing programme was used for data analysis.
The age range of 33 subjects was 40-77 years. Of the total, 12(36.3%) were more than 60 years or older; 29(87.8%) had some level of education with 2(6%) having gone to the university level (Table).
The subjects mostly were from the lower-middle socioeconomic level who had migrated to the city from small villages in search of stable lives. All (100%) were married and had a Muslim background. Ten (30.30%) had regular jobs with monthly salaries, while 20 (69.70%) were either retired or working part-time.
The quotes used in the text were chosen according to the themes that most appropriately defined the situation. In the parenthesis following quotes below, the age has been mentioned first, followed by the job of the participant, and finally the menopausal state of his wife. Turkish translations have been put in italics within parenthesis. Although there is no Turkish word for the term \'menopause\', it is widely referred to as menopoza girmek among educated Turkish people which can be translated as "to enter menopause", but in our study if the men had never heard of the word menopoz it was rephrased and asked what they understood from Adet kesilmesi, or the "cessation of menses".
The meaning of \'menopause\' was associated by 25 (75%) of subjects with a period when women would no longer be able to have a child. The first sentences were linked directly with the ending of the fecundity period.
"She won\'t be able to have a child. She does not see her periods.\'\' (62; technician; wife in postmenopause).
"As far as I know, there will be no children anymore.\'\' (58; driver; wife in menopause).
In our sample, one third of the man believed that menopause was a disease because they observed changes in normal bodily functions and thought that women would no longer be able to have a child.
"It is a disease of course… is not a good thing for women.” (64; farmer; wife in menopause).
"Yes, it is a disease, if it were not a disease the periods would not be cut off." (69; driver; wife in menopause).
"If there will be no longer periods and unable to make children, I think it is a disease." (73; self-employed; wife in postmenopause).
On the other hand, two-thirds of the men did not consider menopause as a disease and thought it was a natural phase.
"Why should I call it a disease? When the time comes, naturally, all women aged 50-55 will enter." (62; technician; wife in menopause).
"I have not seen my wife\'s status as a disease. I said to myself she is getting older." (64; retired; wife in menopause).
Half of the men stated fatalistic views, like "God wanted so", in this context.
"It is the will of Allah." (70; carpenter; wife in menopause).
"It\'s not a disease. It occurs naturally. It happens between the ages of 45-50. It is Allah\'s command (Allah\'in emridir)." (66; retired; wife in menopause).
Another important theme was the association of menopause with cleanliness. In Islamic religion, women cannot fulfil religious services during the menstrual period. Not having periods and "cleanliness" may be related because of those commandments.
"May pray (Namaz kilabilir)as now, she is really clean\'\'. (70; carpenter; wife in menopause).
Another approach was that half of the men thought that menstruation blood is dirty and if it is stuck inside the body it may cause some diseases.
"When woman enters the menopause she cannot drain out the dirty blood and because of this, diseases of the body increase. Blood clotting problems may happen." (62; technician; wife in menopause).
"Accumulation of the filthy blood inside the women leads to various diseases in the organs." (50; foreman; wife not in menopause).
None of the men had heard of treatment modalities for menopause and they perceived the treatment as an effort to have children, and to continue to menstruate. Therefore some of them thought that it would be a coercion to consult a doctor.
"I have not heard of people who applied to a doctor for this. Extending the periods by treatment is an evil thing for women …Some properties of a human being is changing due to old age." (77; retired; wife in menopause).
"There is no cure for this. It would be an enforcement to give drugs to prolong the menstrual cycle." (50; teacher; wife not in menopause).
One-third of the subjects mentioned about the advantages of the prolongation of the menstrual period by treatment.
"If the treatment is given, it prolongs menstrual periods and she may have a child." (62; technician; wife in menopause).
"There may be treatments, experts know it. Women should take this treatment because menstruating women are protected from diseases …Now we have the effects of the menstrual cycle. Without it, there may be side effects." (64; retired; wife in menopause).
"They expect to be cured. For them it is a problem. They do not want to enter menopause. For example, a doctor can cure? They want a longer menstrual period. But I think there is no cure. It would be nice to have a child in the older age, though." (46; officer; wife not in menopause).
Men thought that with menopause women lose femininity and become just like men and, as a consequence, lose interest in sex. Therefore, most of the men were concerned about their own sexual lives.
"There is no such thing as a desire, sexual contact not like before…" (73; self-employed; wife in menopause).
"Women cannot get pleasure. I am not sure whether the pleasure is reduced in men. It did not happen to me. I do not know. Men do not speak of such things among themselves.\'\' (46; officer; wife not in menopause).
In our sample, menopause was perceived as maturity. With the loss of femininity masculinisation occurred, and 30 (90%) of the men thought that with menopause men and women became equal and women were considered more mature and to have increased their status both at home and outside.
"…We are even now…Children and daughters-in-law will listen to her more." (64; retired; wife in menopause).
Twenty-five (75%) of the men were concerned about the weight gain among women during menopause and thought that because of the weight they do not look after themselves as before and their beauty is reduced.
"It depends on women. She becomes fat, she gets heavier. Her mobility, care, beauty all are gone." (62; technician; wife in menopause).
"She is putting on weight. Begins to eat and drink much." (50; foreman; wife not in menopause).
"A little more frayed, her youth goes away. She has weakness. Weight increases. She is more irritable." (64; retired; wife in menopause).
When asked whether they could tell if a woman was in menopause, two-thirds of the participants described the psychological changes that women go through, though one-third of the men did mention the physical changes. They also emphasised about the decrease of libido.
"She is stressful. Does not want the relationship. Diseases of the women (meaning gynaecological in nature) increase. Does not take pleasure from her husband, therefore does not enjoy life." (46; officer; wife not in menopause).
"Would be frustrated. The relationship goes away. Does not want to be disturbed. Would be ill-tempered, nonchalant, irrelevant to the man. She cannot offer everything to her man as she did before." (58; driver; wife in menopause).
"She behaves strangely, she has puniness, will suffer weakness, I can tell from her walking." (69; driver; wife in menopause).
One-third of the men believed that menstruation protected women from diseases. They correlated that among women, having a period was similar to men experiencing an ejaculation. As the men became more relaxed and comfortable after ejaculation, women also felt the same after menstruation. With the menopause, women did not have menstruation and because of this women will be more frustrated and anxious.
"Menstruating women are protected from diseases. If she does not have menstruation, diseases will creep in. For example, she gets an upset stomach, abdominal pain, breast cancer. Now we have the benefits of the menstrual cycle. Man relaxes when he drains off (ejaculation). The same thing happens when women sees her periods." (64; retired worker; wife in menopause).
"(In menopause) there are many harms. Yields to diseases. Like a man if he cannot drain off, (ejaculation) there is harm in it. Women should empty the inside of her body. Otherwise it is harmful." (50; foreman; wife in menopause).
When asked about the possible expectations of women during menopause, 12 (36.3%) of the participants had no idea and thought that there would not be any expectations because as the women gets older they withdraw themselves.
"I think there is no expectation. I mean…she has given up the world, now" (58; driver; wife in menopause).
"She says my period is over. Wallah, I\'m done, she says" (69; driver; wife in menopause).
On the other hand, 13 (39.4%) of the participants mentioned about psychological needs of the women although all related this need with old age.
"She feels old. She requests care and assistance, just like the elderly. Because she is old she expects respect and love from his family" (62; technician; wife in menopause).
Twenty-five (75%) of the men stated that early menopause was associated with "bad habits" like smoking and drinking alcohol. Some other factors which were related to early menopausal age, according to the men, were lower economic conditions, troubles in the households, depression, psychological condition, being thin and living in urban or rural areas.
"If a woman is healthy, has a good economic status, she enters menopause later. Women who have bad financial situation, women with health problems and women who have unrest at home enter menopause early" (64; retired; wife in menopause).
"If the woman is youthful, well-fed, vivid than she enters menopause late. The weak and diseased (anaemic), there would be premature menopause" (66; retired; wife in menopause).
"To live in the city leads to early menopause. Early menopause in women living in the village is not the case" (50; foreman; wife not in menopause).
In our sample, the 25 (75%) of the men described menopause as the period when women would no longer want to continue their sexual life, therefore they thought of menopause in women as impotence among men.
"It is called impotence, would not want the relationship. Tiring for the brain. Once-a-week is enough when you are 50 years old" (46; officer; wife not in menopause).
"In males there is no such thing as menopause. Reduced sexual desire after only 60 years of age. You can have children up to age 80" (64; retired; wife in menopause).
"There is no menopause in men. If he looks after himself well, nothing happens, goes up to 100 years old (meaning sexual desire). It would not happen in the village ... but, here in the city because of hormones in the food" (50; foreman; wife not in menopause).
From the biological point of view, menopause or cessation of the menstrual period is a stage in a woman\'s life that represents a transition from reproductive to non-reproductive life.1 From a psychosocial perspective, it is a period of time when women are at greater risk of suffering emotional problems such as anxiety, irritability and, especially, depression.2,3
Permanent cessation of menstruation is a complicated experience; it is universal yet individualised and the perception of the women may be influenced by bio-psychosocial, cultural and economic factors. Menopausal experiences may vary according to cultural understanding, socioeconomic conditions and social circumstances. In literature, it has often been stated that it is a difficult period with many symptoms. Besides being a major cause of morbidity such as heart disease and osteoporosis, menopause and its consequent hormonal changes also cause symptoms that affect the quality of life (QOL). Many women and their husbands both suffer additional anxiety and distress when unfamiliar and unanticipated symptoms occurr. These problems can also affect the quality of women\'s sexual experiences.4 Furthermore, many women suffer from additional difficulty when their spouse misinterprets menopausal symptoms (vaginal dryness, sexual disinterest) as infidelity.5 Men in this hard period have a very crucial role for women to have a smooth transition into postmenopausal period.
According to the findings of one study that explored depressive symptoms of Turkish women aged 40-65, the women who had the support of their husbands had fewer depressive symptoms.6 Men of all ages can play a critical role in supporting the health of women throughout their life course.
To our knowledge, the current study is the first qualitative effort focussing on Turkish men\'s perceptions on menopause. Understanding these features and their implications in women\'s lives may assist healthcare workers in helping these women and their husbands with menopause.
The current study, to our knowledge, is the first in literature describing perspectives of men about menopause. As such, it serves to fill a gap regarding broader human understanding of the subject.
Overall, the men we assessed lacked basic knowledge about both menstruation and menopause. A qualitative study earlier included 10 men and 10 women and all the participants stated that they were unaware of the menstruation or menopause until the event occurred.5 Many of the women were already married at the time of menarche and relied on their husband\'s knowledge to inform them about menstruation. The information given to these women, however, was very restricted and these women were not alerted to anticipate the physiological nor psychological symptoms associated with menstruation or menopause. Health information given by healthcare workers to women should begin with menstruation, involving men because this basic knowledge will have its effects both in terms of choice of contraception and during menopause.
Men in our sample were reluctant to talk about their wives in front of other men and the idea of talking to a female researcher was unacceptable to them. We think this is also a significant finding. Our subjects did not want to talk to a female researcher probably because they did not like the idea of being "interrogated" or "judged" by a female healthcare worker in a subject they did not know very well. Another issue is that in Turkish culture family is considered sacrosanct, and talking about the relationship between men and women is not a norm. In this context, there are unwritten rules in communication which makes it difficult for both female healthcare workers to communicate with men and vice versa.
Interestingly, menopause status of the wives of our sample was not a strong predictor of perceptions. No significant difference was observed in terms of menopause perceptions between men whose wife was in menopause and those who had wives still menstruating. Likewise, in our sample, the level of education did not have an influence on the perceptions of menopause. Both well-educated and less-educated men had misconceptions and knowledge based on hearsay about menopause.
In our study, men associated the meaning of "menopause" directly with the ending of the fecundity period. In earlier studies, women have also been found to see menopause in a negative way because it means the end of fertility and the end of youth.7 This finding was compatible with a study which indicated that the majority of the women surveyed saw menopause as "the end of youth"; "the beginning of getting older", and as "the end of fecundity".8 Although in numerous studies, many women held the opinion that the climacteric is a normal phase in a woman\'s life, and femininity is not lost in the climacteric period, but in our study men related menopause with the ending of the femininity and the ending of the sexual life.9,10 The main concern in our sample was that the women in menopause lost interest in sex and therefore withdrew from life (Figure).
Continuing to menstruate was perceived as a positive sign for women. Men preferred their wives to continue to menstruate because they did not want their sexual life to come to an end. Furthermore, some of the men related menstruation with ejaculation and thought that as the men felt relaxed after ejaculation, the symptoms of menopause such as irritability, nervousness, will be overcome by menstruation.
As they age, women and men share the basic needs and concerns related to their health. However, the men in our sample had never heard of treatment modalities for menopause and they perceived it as part of efforts to have children, and to continue to menstruate. Therefore, some of them thought that using medicine for menopause would be distorting the natural course of events and it would be a coercion to consult a doctor. In several studies, women have reported that they had not used any hormone therapy, any medicine for the distress or the insomnia that menopause causes, and any calcium supplement concerning menopause.9,11 These findings indicated that women were not willing to take medication for menopausal symptoms. Probably in our sample too, men might not have witnessed any women taking medicine for their menopausal symptoms and were unaware of the treatment modalities for menopause.
Interventions are needed to increase men\'s awareness, especially on common physiological and psychological disturbances during the menopause transition. Such initiatives would hopefully lead to a supportive environment that menopausal women need from their partners. There is a need to involve men when delivering health information to women.
1. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. Philadelphia: Lippincott Williams &Wilkins, Cop; 2005.
2. Deeks AA. Psychological aspects of menopause management. Best Pract Res Clin Endocrinol Metab 2003; 17: 17-31.
3. Hartmann U, Philippsohn S, Heiser K, Ruffer-Hesse C. Low desire in midlife and older women: personality factors, psychosocial development, present sexuality. Menopause 2004; 11: 726-40.
4. Palacios S, Tobar AC, Menéndez C. Sexuality in the climacteric years. Maturitas 2002; 43: 69-77.
5. Michel JL, Mahady GB, Veliz M, Soejarto DD, Caceres A. Symptoms, attitudes and treatment choices surrounding menopause among the Q\'eqchi Maya of Livingston, Guatemala. Soc Sci Med 2006; 63: 732-42.
6. Bayraktar R, Uçanok Z. [A review of the attitudes toward menopause and cross-cultural studies]. Aile ve Toplum Dergisi 2002; 5: 12-25.
7. Castelo-Branco C, Palacios S, Mostajo D, Tobar C, von Helde S: Menopausal transition in Movima women, a Bolivian Native-American. Maturitas 2005; 16: 380-5.
8. Ayranci U, Orsal O, Orsal O, Arslan G, Emeksiz DF. Menopause status and attitudes in a Turkish midlife female population: an epidemiological study. BMC Womens Health. 2010; 11: 10:1.
9. Hovi SL, Veerus P, Karro H, Topo P, Hemminki E. Women\'s views of the climacteric at the time of low menopausal hormone use, Estonia 1998. Maturitas 2004; 16: 413-25.
10. Malik HS. Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women. J Pak Med Assoc 2008; 58: 164-7.
11. Nusrat N, Nishat Z, Gulfareen H, Aftab M, Asia N. Knowledge, attitude and experience of menopause. J Ayub Med Coll Abbottabad 2008, 20: 56-9.