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Pattern of Psychosomatic Illness after menopause

Chapter-I

Introduction

1.1. Background:

Menopause is a normal physiological event in women’s life and is the part of normal aging. The World Health Organization (WHO) and the Stages of Reproductive Aging Workshop (STRAW) working group define menopause as the permanent cessation of menstrual periods that occurs naturally or is induced by surgery, chemotherapy or radiation. Natural menopause is recognized after twelve consecutive months without menstrual periods that are not associated with a physiologic (e.g. lactation) or pathologic cause.¹

Menopausal women have losses their reproductive capacity due to permanent cessation of ovarian functions. The normal age range for the occurrence of menopause is some where between the age of 45 and 55. Last period occurring after the age of 55 is known as a “late menopause”. An “early menopause” on the other hand is defined as last period ever between the ages of 40 to 45.²

It is projected that by the year 2030 the total number of menopausal women will be approximately 1200 million, with 47 million entrants each year. The proportion of menopausal women is increasing everywhere and the proportion of those living in the developing world will increase to 76%. Most dramatic increase will be in China from 8% to 17% and from 15% to 23% will be in the industrialized countries. ^3,4

The number of menopausal women in the United States by the year 2025 projected to double from mid 1990s, and about half million midlife women will be added every year for the rest of this decade.⁴

According to the World Development Report, the proportion of women aged 50 and over of 11 countries (except Japan) in the East Asia region of the world in 2010 and 2030 will be 11.28% and 17.08%, respectively. These figures suggest, sharp increases in the proportion of menopausal women over the next 20-30 years in the countries of East Asia. Due to increasing the life expectancy at birth, the future menopausal population will increase dramatically in the developing world more so than in the industrialized world.^5,6

According to the report of Bangladesh Bureau of Statistics 2005, the menopausal women in Bangladesh was 14% of the female population and increasing with increase of life expectancy.⁷

In general, however, menopause causes the following symptoms:

Ø Hot flushes

Ø Night sweats

Ø Vaginal changes- dryness, itching, decrease libido

Ø Urinary changes- frequent urination, urine incontinence

Ø Insomnia

Ø Mood changes-depression, irritability, tension

Ø Anxiety

Ø Memory loss, and problem with concentration

Ø Variety of mental and emotional disturbances ranging from mild to very severe

These symptoms mainly occur due to deficiency of some hormones. Due to hormonal imbalance every woman can have a different kind of menopausal experience, depending upon what she had done with her life experience, her stresses, her heredity, her diet, her beliefs, the manner in which she faces life and her purpose for being here.^7,8 The menopausal symptoms vary from country to country, race/ethnicity, tradition, socioeconomic conditions and person-to-person.⁴

White women had increasing trends of nervousness, memory loss, vaginal dryness, loss of sexual interest, hot flushes and night sweats while Africans women only had increasing trend of painful sex and hot flushes. ²

Middle aged Chinese women living in Sydney had slightly higher prevalence of vasomotor symptoms than Chinese women in Mainland China or Hong Kong, but a lower prevalence of symptoms than Caucasian women. These findings suggest that cultural environment plays a significant role in showing menopausal symptoms.⁹

Study in Mexico showed that depression and anxiety were less in urban and educated women than the rural and less educated women. Hot flushes, vaginal dryness, and diminished sexual interest increase with age.¹⁰

A study was conducted in two Union of Gazipur district of Bangladesh on rural menopausal women. It showed that among study population 60% had suffered menopause related problems and the symptoms had no relation with socio-demographic characteristics. Larger proportion (48%) of menopausal women reported weakness, vertigo, aches and pain all over the body and joints, and tingling of hands and feet. But hot flushes and sweating found only in 14.7%. ¹¹

Menopause Rating Scale (MRS) measures the menopausal symptoms. It is an important tool for assessing the health related quality of life of women after menopause. The scale was developed in 1990s in Germany and since then validated step by step. It is composed of 11 items and 5 scoring of severity. This scale is used to grading the symptoms and compares the severity of symptoms. Individual score of these 11 items is called sub-scores and total score is measured by adding the sub-scores. Score within 0-4 indicates no symptoms, than 5-8 indicates mild, 9-15 indicates moderate and score 16+ indicates severe symptoms.¹²

Diagnostic Criteria for Psychosomatic Research (DCPR) is a diagnostic system, which has developed to measure psychosomatic symptoms. In 1995, an international consortium of psychosomatic investigators developed this set of criteria. It is an operational tool for the assessment of psychological distress containing 58 questions with “yes” or “no” answers. Diagnosis of psychosomatic disorders is done on the basis of the answers of this DCPR questions.³⁴

There were some studies on rural menopausal women of Bangladesh but study on urban menopausal women in Bangladesh lacks. Present study was undertaken to find out the menopausal symptoms and psychosomatic illness pattern after menopause in urban population. Results of this study will help the researcher and policy makers to formulate preventive and promotive measures for healthy life of menopausal women.

1.2 Justification:

The World’s elderly population is rapidly increasing. Bangladesh, with its limited resources, will have to face major challenges in providing adequate health care facilities for its increasing number of future older population. At present in our country life expectancy of women is about 65.4 years and the country is now one of the top twenty countries of the world with the largest older population. Among the population almost 50% are women. In Bangladesh on average menopause occur between the ages 45 to 50 years. So, total numbers of menopausal women increasing with increase of life expectancy.

The International Conference on Population and Development (ICPD) held in Cairo in 1994 and the fourth world conference on women in Beijing in 1995 have given importance on comprehensive reproductive health care based on the life cycle approach. As such, issues related to menopause and necessary health care are an important component of the health services for women.

It is important to discuss the demography of the menopausal population. It is also necessary to evaluate the menopause related and psychosomatic symptoms in each country. These symptoms reduce the quality of life of the menopausal women. There are many approaches to reduce these symptoms such as life style modification, physical activities, changes of food habit and also taking hormones.

In Bangladesh, women play multiple important roles in the society. Happiness of the family depends mainly upon women. But after menopause women facing menopausal and psychosomatic syndromes may have direct impact on her family life.

Effective health care can be the most effective measure to maintain a good health after menopause. Selected screening and education should be an integral part of health care for women after menopause. There is scarcity of information on menopause, menopausal symptoms including its status, socio-cultural significance, and psychosomatic illness after menopause. Most of the research works on menopause were done in the developed countries and already took effective measures to relief these problems.

In developing country like Bangladesh, there are few epidemiological data regarding menopausal symptoms of women in rural area but there is paucity of study on information about menopausal symptoms and psychosomatic illness of urban menopausal women.

Besides, health care providers also have lack of knowledge about the needs and concerns of menopausal women. As a result health needs of menopausal women remain under served and neglected. In order to improve the health quality of menopausal women, we need in-depth data about status of menopausal symptoms and psychosomatic illness pattern.

Therefore, present study was undertaken to find out and determine the types of menopause related and psychosomatic illness after menopause to provide some essential baseline information which will be useful for planning program by policy makers and delivery of health care services by the health care providers to support them during this period. The results of this study will also be the basis for future nation wide study to get detailed information regarding menopause.

1.3. Research question:

What are the psychosomatic illnesses faced by the women after menopause?

1.4. Objectives:

A. General objectives:

To determine the psychosomatic illness pattern of the menopausal women of a selected urban area.

B. Specific objectives:

1. To determine the socio-demographic characteristics of the menopausal women of a selected urban area.

2. To determine the severity of menopausal illness of respondents by using Menopause Rating Scale (MRS).

3. To find out the pattern of psychosomatic illness among the study subjects by using Diagnostic Criteria for Psychosomatic Research (DCPR).

1.5. List of key variables:

1.5.1. Background variables:

a. Age

b. Religion

c. Marital status

d. Educational status of respondents and their husband

e. Main occupation of the respondents and their husband

f. Monthly family income

g. Duration of menopause

1.5.2. Menopausal symptoms related variables: Severity determined by Menopause

Rating Scale (MRS), which included the following variables

a. Hot flushes, sweating

b. Heart discomforts

c. Sleep problems

d. Depressive mood

e. Irritability

f. Anxiety

g. Physical and mental exhaustion

h. Sexual problems

i. Bladder problems

j. Dryness of vagina

k. Joint and muscular discomfort

1.5.3. Psychosomatic illness pattern related variables: Diagnostic Criteria for

Psychosomatic Research (DCPR) constituted of

a. Health anxiety

b. Disease phobia

c. Thanatophobia

d. Illness denial

e. Functional somatic symptoms secondary to a psychiatric disorder

f. Persistent somatization

g. Conversion symptoms

h. Anniversary reaction

i. Type A behavior

j. Irritable mood

k. Demoralization

l. Alexithymia

1.6. Operational definitions:

1.6.1. Menopause related symptoms

a. Menopause:

Current study only included natural menopause. Natural menopause is recognized to have occurred after twelve consecutive months of amenorrhea for which there is no other obvious physiological (lactation) or pathological causes.

b. Hot flushes, sweating:

It is characterized by sensation of warmth accompanied by skin flushing and profuse sweating. Usually these symptoms arise from trunk and move upwards and towards shoulders, neck and head.

c. Heart discomfort:

It means feeling of unusual awareness of heartbeat, heart skipping, heart racing, and chest tightness.

d. Sleep problems:

It means difficulty in falling asleep, sleeping through, and waking up early.

e. Depressive mood:

This is a condition of feeling down, sad, on the verge of tears, lack of drive, and mood disorder.

f. Irritability:

Feeling of excitability, anxious, aggressive, inner tension and feeling nervous.

g. Anxiety:

It is a restless condition with feeling of sudden uncontrollable fear.

h. Physical and mental exhaustion:

Any complain of general decrease in performance, impaired memory, lack of concentration, and forgetfulness.

i. Sexual problems:

It is a type of change in sexual desire, sexual activity and satisfaction.

j. Bladder problems:

Any complain of difficulty in micturition, increase frequency of micturition, and bladder incontinence.

k. Dryness of vagina:

A sensation of dryness or burning in the vagina, and complain of painful inter course.

l. Joint and muscular discomfort:

It is the suffering from pain in the joints, or rheumatoid complaints.

1.6.2. Psychosomatic symptoms

Psychosomatic syndromes mean psychological distress in patients with somatic ailments.

a. Health anxiety:

Worry about serious illness, worrying too much and goes to doctor for any types of illness like headache or a cold, worries and fear respond to medical reassurance. This type of feeling persist for more than six months even though new worries may ensue after some times.

b. Disease phobia:

Persistent unfounded fear of suffering from a specific disease and the object of the fear do not change with time and duration of symptoms exceeds six months.

c. Thanatophobia:

It means attacks with the sense of impending death and or conviction of dying soon, even though there is no objective medical reason for such fear. Any news, which reminds of death, provokes an immediate anxiety response.

d. Illness denial:

Persistent denial of having a physical disorder and of need of treatment, e.g. lack of compliance, delayed seeking of medical attention for serious and persistent symptoms, counter phobic behavior.

e. Conversion symptoms:

Describes a condition in which physical symptoms arise and for which there is no clear explanation. It needs repeated medical care for which decrease quality of life.

f. Functional somatic symptoms:

Symptoms of autonomic arousal (e.g. palpitation, sweating, tremor, flushing) or functional medical disorder (e.g. Irritable bowel syndrome) causing distress or repeated medical care, or resulting in impaired quality of life with out any real cause. There is no organic pathology regarding this physical complains.

g. Anniversary reaction:

Symptoms of autonomic arousal (e.g. palpitation, sweating, tremor, flushing) or functional medical disorder (e.g. Irritable bowel syndrome) causing distress or repeated medical care, or resulting in impaired quality of life with out any real cause. There is no organic pathology regarding this physical complains. The “anniversary reaction” began at the anniversary when parent or very close family member developed above illness or died.

h. Persistent somatization:

Functional medical disorder (e.g. fatigue, esophageal motility disorders, and Irritable bowel syndrome) whose duration exceeds six months, with additional autonomic arousal (e.g. palpitation, sweating, tremor, flushing) causing distress or repeated medical care, or resulting in impaired quality of life.

i. Demoralization:

This is the feeling of person’s consciousness of having failed to meet his or her own expatiations or being unable to cope with some pressing problems such as feelings of helplessness, hopelessness or giving up. The feeling state should be prolonged and generalized at least one-month duration and closely antedated the manifestation of the medical disorder or exacerbation of its symptoms.

j. Irritable mood:

It is characterized by irritable mood, which may be brief or prolong and generalized, required increased effort to control over temper by the individual. In this condition it also cause uncontrollable verbal or behavioral out bursts and unpleasant sensation.

k. Type-A behavior:

The behavior elicits stress-related physiologic responses that precipitate or exacerbate symptoms of a medical condition and at least 5 of the following 9 conditions must be present.

Ø Excessive degree of involvement in work and other activities subject to dead lines.

Ø Steady and pervasive sense of time urgency.

Ø Display of motor-expressive features indicating sense of being under the pressure of time.

Ø Hostility and cynicism.

Ø Irritable mood.

Ø Tendency to speed up physical activities.

Ø Tendency to speed up mental activities.

Ø High intensity of desire for achievements and recognition.

Ø High competitiveness.

l. Alexithymia:

At least 3 of the following 6 characteristics should be present

Ø Inability to use appropriate words to describe emotions.

Ø Tendency to describe details instead of feelings.

Ø Lack of a rich fantasy life.

Ø Thought content associated more with external events rather than fantasy or emotions.

Ø Unawareness of the common somatic reactions that accompany the experience of a variety of feelings.

Ø Occasional but violent and often inappropriate out burst of affective behavior.

1.6.3. Severity of menopausal illness:

Severity of menopausal illness can be measured by grading of the menopausal symptoms. Grading obtained by the scoring of symptoms by using Menopause Rating Scale. Scores within 0-4 indicates no symptoms, 5-8 indicates mild, 9-15 indicates moderate and score 16 and more indicates severe symptoms

1.6.4. Pattern of psychosomatic illness:

Pattern of psychosomaticillness means types of psychosomatic illness presented by the respondent. It is measured by using the Diagnostic Criteria for Psychosomatic Research based questionnaire of fifty-eight items and diagnosis is done by on the basis of answer of these items.

Chapter-II

Literature review

To conduct the research on psychosomatic illness pattern after menopause; menopausal symptoms and psychosomatic illness related literatures were searched and reviewed from the library of ICDDR, B, National Health Library and the Library of NIPSOM. Some articles were collected by Internet search and through personal contact with the authors.

2.1 Menopause

Menopause is a time of a women’s life when reproduction ceases. It is a natural physiological process. The term natural menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is recognized to have occurred after 12 months of amenorrhea, for which there is no other obvious pathological causes. The age at which natural menopause occurs is between the ages of 45-55 years for women worldwide. Women spent a significant part of their lives in the post-menopausal state. During the menopause, ovarian hormone level declines and pituitary gonadotrophin hormone level increases. Due to the changes in hormonal level, women face varieties of symptoms. Most of these symptoms are self-limiting and not life threatening but some symptoms are unpleasant and need medical attention. ^3,7

2.2 Measuring the menopausal symptoms: Menopause Rating Scale (MRS)

The Menopause Rating Scale (MRS) is obviously a valuable tool for assessing health related quality of life of women after menopause and is used worldwide. The currently available nine language versions have been following international standards for the linguistic and cultural transition of quality of life scales. The Menopause Rating Scale (MRS) was initially developed in the early 1990s to measure the severity of age-menopause–related complaints by rating a profile of symptoms, i.e. with the objectives (a) to enable comparisons of the symptoms of aging between groups of women under different conditions (b) to compare severity of symptoms over time, and (c) to measure changes pre and post treatment. The standardization of this scale was performed on the basis of a representative sample of 500 German women aged 45 to 60 years in 1996. A factorial analysis was applied to establish the raw scale of complaints or symptoms. Statistical methods were used to identify the dimensions of the scale. In the past few years, there has been emerging awareness about the importance of sub clinical symptoms, which may have a considerable impact on quality of life and have patho-physiological and therapeutic implications. The scale was defined as a menopause–specific, health related quality of life scale, because the profile of complain in this scale importantly determines the health related quality of life of women in this age span. An internationally well accepted menopause-rating scale consists of 11 items and scoring system are divided according to the severity of symptoms.^12,13,14

2.3 Menopausal symptoms:

Commonly reported menopausal symptoms, including vasomotor symptoms (hot flushes and sweating), vaginal symptoms, urinary incontinence, sleep problems, sexual dysfunction, depression anxiety, mood changes, memory loss, fatigue and joint and muscular pain. But the symptoms may vary with person, culture, and race/ethnicity, social and economic status.⁷

2.3.1 Menopausal symptoms and age

Neugarten and Kraines conducted a study on menopausal symptoms in women of various age. They found that 45-54 years age group had more hot flushes (68%) and Body pain (46%) than 55-64 years that had (40%) and (32%) respectively. Irritability and nervousness had also more in 45-54 years (92%) than 55-64 years (48%). Worry about body, feeling of fright or panic had 24% and 22% in the age group 45-54 years but only 9% in 55-64 years. On the other hand, sleep problems were higher in 55-64 years (58%) than 45-54 years (51%). ¹⁵

2.3.2 Menopausal symptoms and social factors

A cross-sectional descriptive study conducted by Uncu et al. on The perception of menopause and hormone therapy among in Turky. Among 1007 respondents 86% women had hot flushes and various types of menopausal symptoms. All the menopausal symptoms were influenced by cultural variations, level of education and social factors.¹⁶

Women’s health in midlife: the influence of the menopause and social factors and health were examined by Kuh et al. on the British women of 47 years. They found that natural menopausal women suffered from joint pain, anxiety or depression, irritability, sleep problems forgetfulness, fearfulness. 60% women had vasomotor symptoms, 35% had sexual problems and 63% had sleep problems. Women with least education had more vasomotor and other general symptoms of menopause than educated women of same age.¹⁷

Juang et al. conducted a research to explore the relationship between anxiety, depression, vasomotor symptoms and menopausal symptoms among middle aged women. A total 1273 menopausal woman were included in this study. They found anxiety and depressive mood associated with menopausal symptoms i.e. psychosomatic problems influences menopausal symptoms. Results showed that menopausal women with hot flushes had anxiety score 6.0±3.8 but with out hot flushes the score was 4.1±3.1. Women with hot flushes also had higher depression score (4.0±3.3) than with out hot flushes (3.2±2.7). ¹⁸

2.3.3 Menopausal symptoms and race/ethnicity

Research on menopause: lessons from anthropology were done by Lock. This comparative study was conducted on 1225 Japanese, 1307 Canadian, 7802 in USA menopausal women. The results showed that 19% Japanese menopausal women suffered from hot flushes, 10.3% from depression, 14.2% from joint pain, 6% from lack of energy, 11.5% from irritability and 11.7% from sleep problems. In case of Canadian women suffered joint pain 31.4%, lack of energy 39.8%, depression 23.4%, sleep problems 30.4%, hot flushes and night sweats 36.4%. In USA 38.6% menopausal women suffered from joint pain, 38.1% from lack of energy, 39.9% from irritability, 35.9% from depression, 34.8% from sleep problems, 38% from hot flushes and night sweats. All these results confirmed a significant difference of menopausal symptoms among the different race of menopausal women.¹⁹

A study was done by Gold et al. on relation of demographic and life style factors to symptoms in multiracial/ethnic population of women 40-55 years of age. The study was conducted in seven geographic areas in the United States on 16065 menopausal women. Women of education below 8 levels had more menopausal symptoms and gradually decrease the symptoms with increase of education level. African American had more hot flushes (45.6%) followed by Hispanic (35.4%), Caucasian (31.2%), Chinese (20.5%) and Japanese (17.6%). Urine leakage, heart pounding and vaginal dryness were more in Hispanic women than women of other race. Joint pain was more in African women. Level of forgetfulness was more in African American than Chinese and Hispanic, and than Caucasian and Japanese. They also found that hot flushes, sleep problems and heart pounding were more in separated/divorced and widowed than the married women. Heart pounding or racing, forgetfulness and difficulty in sleeping increased in women who were not employed fulltime.²⁰

Greendale et al. has done a research on the menopause. They found that hot flushes vary from person to person and commonly start before menopause. The proportion of hot flushes as great as 80% in western countries but as low as 10% in some East Asian countries. Hot flushes diminished spontaneously as time of menopause increases.²¹

Menopausal symptoms find out in Hispanic women and compare with Caucasian women by Schnatz et al. Research was conducted on 404 postmenopausal women of which 50% Hispanic and rest 50% were Caucasian. This was a prospective study. Their results showed that, mood changes occur 76% in Hispanic and 54% in Caucasian. Decrease in energy 56% in Hispanic and 36% in Caucasian. Palpitation was 54% in Hispanic and 26% in Caucasian. Breast tenderness 39% in Hispanic and 28% in Caucasian, memory loss 34% in Hispanic and 22% in Caucasian, and vaginal dryness 34% in Hispanic and 44% in Caucasian, hot flushes were found 80% in Hispanic and 75% in Caucasian, Night sweats 67% in Hispanic and 64% in Caucasian.²²

2.3.4 Menopausal symptoms in urban vs. rural

Malacara et al. conducted a research to compare the menopausal symptoms between urban vs. rural area of Mexico. Their results showed that mean menopausal age rural vs. urban was 50.9± 4.4 and 49.8±3.28 years respectively. Hot flushes were more in urban (72.8%) than rural area (62.5%), anxiety score was more in urban (8.9±6.1) than rural area (7.6±5.9) and dispareunia was more in urban (22.0%) than rural (18.1%). On the other hand dryness of vagina was more in rural (41.4%) than urban (37.9%) area. ¹⁰

2.3.5 Menopausal symptoms in developed countries

A study was conducted by Chedraui et al. to determine the frequency and intensity of menopausal symptoms as well as associated risk factors among healthy middle-aged Ecuadorian women. Their results showed that 97% had hot flushes and sweating. Heart discomfort 38.2%, sleep problems 61.8%, muscle and joint pain 79.4%, depressive mood 67.6%, irritability 73.5%, anxiety 20.6%, physical and mental exhaustion 85.3%, sexual problem 91.2%, dryness of vagina 61.8% and bladder problems were 79.4%. ²³

Sievert et al. examined how attitudes toward menopause in relation to symptom experience in Puebla, Mexico. Over 90% of the sample was aged 40-60 years. Participants were asked to select from a set of dichotomies to describe, “How a woman feels during menopause”. They found that menopausal woman feels “insecure” and “unattractive”. Post menopausal women and women with fewer years of education were significantly more likely to report symptoms such as hot flushes, joint aches and nervosa tension. A range of negative attitudes were associated with nervous tension, feeling blue, and head aches.²⁴

A study was conducted by Berg and Taylor to describe the experiences of menopausal symptoms among the Filipino American midlife women with particular emphasis upon estrogen-related menopausal symptoms (day sweats, hot flashes, night sweats and vaginal dryness). They found that vaginal dryness 39.4%, hot flushes 37.6%, day sweats 21.9% and night sweats 24.2%. Subject chi² tests indicated that 50–56 years old women were more likely to report fatigue/sleep symptoms, physical symptoms, and estrogen-related menopause symptoms than all other age groups.²⁵

Liu and Eden conducted a research on experience and attitude toward menopause in Chinese women living in Sydney. This cross sectional study was conducted among 310 Chinese women of age 45-65 years. They found that mean age of menopause 50.3 years. All respondents reported a high prevalence of poor memory (76%). Pain in the muscle and joints (68%), Hot flushes and night sweats were by 34% and 27%. 55% of menopausal women complained of frequent urination. 90% and 60% of respondents reported vaginal dryness and sexual problems. In this study they also found that, lower educated women had more vasomotor, psychosocial and physical symptoms. Respondents who had lived long time in Australia reported more physical symptoms than who are living in main land China .⁹

2.3.6 Menopausal symptoms in Asia

Pan et al. designed a cross-sectional study by using structured questionnaires in Taiwan. The study was conducted in 386 women. They found that, most common acute menopausal symptoms were insomnia 42%, hot flushes 38%, heart palpitation 34%, irritable temper 34%, dyspareunia 32%, Headaches or dizziness 28%, lack of energy 26%, depression 20%, night sweating 18% and loss of bladder control 16%.²⁶

Punyahotra et al. describes the menopausal experiences of Thai women. Part 1: symptoms and their correlates. This study was a cross-sectional survey of mid-aged Thai women with the following aims: to describe their experience of symptoms and attitudes to menopause and to examine the relationships between symptoms, attitudes to menopause and socio demographic variables. The symptoms that showed strongest association with menopause were joint pain, hot flashes, depression and insomnia. Women most likely to experience of such symptoms were older than 50 years of age, little education and house wives .²⁷

A study conducted by Kumari et al. to examine the changes in health functioning as women progress through the menopausal transition. It was a longitudinal study of 1813 Australian women. They showed the severity of menopausal symptoms. Severity of vasomotor symptoms showed that 7% suffered from severe problems, 9% moderate, 14% mild and 41% had no symptoms.²⁸

A research was conducted by Shakhatreh and Mas’ad on 143 women of Jordan aged 50-65 years to identify the menopausal symptoms. Women were asked about a link of somatic symptoms, psychological, genitourinary, urinary tract infection, hypertension and also diabetes mellitus. They found that mean age of menopause was 50 years. 77% of women were illiterate, and 59% couples were relatives. The most frequently reported somatic symptoms were joint aches/stiffness, which were 89%. Bone pains 74%, and paresthesia in the extremities were 51%. Hot flushes were experienced by 62% and urinary incontinence by 30%. Almost 62% reported irritability and mood changes. ²⁹

Yahya and Rehan under took a study, to explore the age, pattern and symptoms of menopause among rural women of Lahore. Pakistan. They found that, the mean age at menopause was 49± 3.6 yrs. The majority of women (22.3%) reached menopause at 50 years followed by 13.9% at 49 years. In 66.2% cases, the onset of menopause was sudden. The symptoms associated with menopause were Lethargy 65.4%, forgetfulness 57.7%, urinary symptoms 56.2%, Agitation 50.8%, depression 38.5%, insomnia 38.5%, and hot flushes 36.2%. They also found that, mean age of menopause of their study was lower than that reported for Caucasian, Thai and Malaysian women, but higher than that reported from Iran, Egypt, Turkey and UAE.³⁰

2.3.7 Menopausal symptoms: Bangladesh situation

Naher et al. conducted a study on menopause in rural Bangladeshi women. It was observed from her study that 48% suffered from menopausal symptoms. Weakness vertigo, pain in the joints and bones were top most problems. Sleep problems were the next common complains. 17.9% complained urinary disturbances. Hot flushes and sweating were complained by 25.5%. Anxiety and depression 17%, Irritable temper 13.9% and Parasthesia observed by 33%. ¹¹

Sultana conducted another study on menopausal status and reproductive behavior in rural women. She found that more than 52% complained hot flushes. 52% had mood change and of them 90% had irritability, 8% had depression. More than 50% suffered from mild to severe sleep disturbances. Sexual desire was changed in 88.7% menopausal women.³¹

Khanum conducted a research to see the knowledge on menopause among the women of a selected community in rural area of Bangladesh. She observed that majority of menopausal women had muscle pain (53.3%), mental anxieties were 31.6% and Hot flushes were 17.5%. ³²

2.3.8 Measuring the psychosomatic illness

Twelve psychosomatic syndromes, four of them were conceived to provide a better specification of the DSM-IV rubric of psychological factors affecting medical conditions (i.e. alexithymia, type-A behavior, irritable mood, and demoralization). The other eight diagnostic criteria were concern with clinical phenomena related to the process of somatization and were developed as substitutes for or supplementary to the DSM categories of somatoform disorders. These new diagnostic criteria encompassed disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms, persistent somatization, conversion symptoms and anniversary reaction.³³

Psychosomatic illness means unexplained physical symptoms with out organic cause. It is one type of psychiatric disorder. DSM-IV and ICD-10 are most widely used diagnostic system in characterizing psychosocial problems in medically ill persons. In fact the definition of psychiatric disorders presenting with predominantly somatic symptoms with in DSM-IV and ICD-10 such as somatoform/psychosomatic disorders has significant shortcomings i.e. some disorders, emerging awareness in psychiatry that psychological symptoms do not reach the threshold of a psychiatric disorder but may affect the quality of life. In 1995 an international consortium of psychosomatic investigators drawing on this type of criticism of DSM definitions of somatoform disorders, psychological factors affecting medical conditions, and adjustment disorders and corresponding ICD-10 categories, suggested that a more useful approach to delineating psychological distress in patients with somatic ailments would be operationalizing and studying the distribution of so called psychosomatic syndromes. They developed sets of criteria for 12 syndromes called The Diagnostic Criteria for Psychosomatic Research (DCPR).^{34, 35}

2.3.9 Psychosomatic illness in menopausal women

In community people of northern Italy, a study had done by Mangeeli et al. using Diagnostic Criteria for Psychosomatic Research (DCPR). They took 347 subjects from general population and found that 260 subjects had DCPR syndrome. 59% had at least one DCPR syndrome. They also found that 25% type A behavior, 15% alexithymia, 5% health anxiety, 3% functional somatic symptoms, 3% illness denial, 3% demoralization, 3% conversion symptoms, 2% anniversary reaction, 2% persistent somatization, 1% disease phobia and 1% thanatophobia.³³

This diagnostic system applies by Galeazzi et al. particularly to the setting of physical illness, where most psychological symptoms cannot be assigned to a suitable rubric according to psychiatric diagnostic criteria. The aim of the Diagnostic Criteria for Psychosomatic Research (DCPR) was to translate psychosocial variables derived from dimensional instruments that were used in the psychosomatic literature into operational categories whereby individual patient groups could be identified. Their study populations were 100 and research was conducted by face-to-face interview. Results showed that demoralization 17.8%, alexithymia 13.2%, illness denial 13.2%, type A behavior 11.4%, health anxiety 9.6%, disease phobia 8.7%, irritable mood 6.9%, persistent somatization 6.3%, thanatophobia 5.5%, anniversary reaction 4.6%, conversion symptoms 2.3%.³⁶

A research on change in psychological and vasomotor symptoms reporting during the menopause was conducted by Hardy and Kuh The association between changes in menopausal status and psychological symptoms was investigated and the effects of changing menopausal symptoms were compared with life events and difficulties. Their findings suggest that menopausal symptoms are dependent on changing of hormone levels associated with the menopause while psychological symptoms were more associated with current life events and difficulties, particularly those experienced in family life than with menopause.³⁷

Studies are available on menopausal symptoms and psychosomatic illness of menopausal women in developed countries. But, there is a lack of such research in Bangladesh so far reviewed. A few research were found which done on rural women. The present study was undertaken to see the pattern of psychosomatic illness after menopause among urban Bangladeshi women.

Chapter-III

Methods and materials

This study was conducted with the aim to find out the pattern of psychosomatic illness and grading of the menopausal symptoms.

3.1. Study design: A cross sectional type of descriptive study was conducted in menopausal women of a selected urban area.

3.2. Study population:

Natural menopausal women of Shaheenbag, Nakhalpara and Arjat para area of Tejgaon, Dhaka were included as study population of this research. Menopausal women were selected by taking history of duration from last menstrual cycle. For this study generally accepted definition of menopause “cessation of menstruation for consecutive twelve months without any physiological and pathological reasons” was used. Study population was selected according to inclusion and exclusion criteria.

Inclusion criteria:

i. Natural menopausal women

ii. Willing to participate

Exclusion criteria:

i. Pregnancy

ii. Lactation

iii. Women of surgical menopause

iv. Known case of mental illness

3.3. Study place:

Study was conducted in Shaheenbag, Nakhal para and Arjat para of Tejgaon, Dhaka. These places were selected because different classes of people are living here who represents the general urban population.

3.4. Study period:

The total study period was from February to June 2008. Data were collected from 7^th April to 21^st April 2008. A detailed work schedule is attached as annexure.

3.5. Sample size:

Total 15 days were allocated for data collection. To ensure the quality of data collection 11-13 respondents per day were interviewed. Therefore, data from total 169 respondents were collected during this period.

3.6. Sampling technique:

Both the study places and subjects were selected by a purposive sampling. Data were collected from desired respondents who were willing to participate in this study.

3.7. Data collection instrument:

Initially a written English questionnaire was developed based on Menopause Rating Scale (MRS) and Diagnostic Criteria for Psychosomatic Research (DCPR) and then translated into Bangla. The questionnaire was prepared by using selected variables according to the objectives and was pre-tested on 20 respondents with characteristics similar to the study subjects in Azimpur area of Dhaka. After necessary modifications the questionnaire was finalized. Bangla questionnaire was used for data collection.

3.8. Data collection technique:

Data were collected from the respondents by face-to-face interview in a private place.

3.9. Data processing and analysis:

Menopause Rating Scale (MRS) based questionnaire includes eleven items and five scoring of severity and total score is measured by adding the sub scores. Scores within 0-4 indicates no symptoms, 5-8 indicates mild, 9-15 indicates moderate and score 16 and more indicates severe symptoms. Scoring was done by the answer of face-to-face interview. Diagnostic Criteria for Psychosomatic Research (DCPR) based questionnaire includes fifty-eight items and the diagnosis was done on the basis of answer of these items. Any mistake was corrected immediately. Data cleaning was done meticulously when entering into computer. All data were processed in computer by SPSS program. Frequency and cross tables were produced. ?²-test was done to see the influence of socio-demographic variables on menopausal symptoms and psychosomatic illness.

3.10. Limitations of this study:

1. The study was conducted in a selected area of Dhaka city. Moreover, only a limited number of menopausal women were included in the study and they were recruited purposively. Therefore, the findings of the study might not reflect the general menopausal women of Bangladesh.

2. The data were collected as reported by the respondents and researcher could not verify further. So, there was chance of recall bias.

Chapter-IV

This descriptive cross sectional study was carried out among 169 menopausal women. After collection, data were analyzed by SPSS software and presented in this chapter under a few headings.

4.1. Socio-demographic characteristics of the respondents

This section describes the background characteristics of the study samples

4.1.1. Age

The mean±SD age of the respondents was 52.63± 4.52 and ranged between 45 and 60 years. Majority of the respondents (39.6%) were within the age group of 55 years and above.

4.1.2. Religion

Among the respondents 154 were Muslims and rest were Non-Muslims of which 12 Hindus and 3 Christians.

4.1.3. Marital status

About 59% of respondents were married and others were unmarried (0.6%), widowed (36.1%), divorced (3.6%), and separated (1.2%).

4.1.4. Educational status

More than one-third of the study samples never went to school and one-fifth of them had only study up to primary level of education. One-tenth of the respondents had HSC and higher level of education

4.1.5. Occupation

More than three-fourth of respondents was housewives and only 22.2% were working women (i.e. service holders, garments workers, day laborers, housemaids, and school teachers).

4.1.6. Monthly family income

Mean±SD monthly family income of the respondents was Tk. 20970.41+18267.82 and ranged between Tk.1500 and Tk.120000. Maximum respondents (30.8%) were in income group of Tk.10001-Tk.20000.

Table-4.1. Socio-demographic characteristics of the respondents

n=169

Characteristics	Frequency	Percentage
Age (years)
45 – 49 50 – 54 55 and above	48 54 67	28.4 32.0 39.6
Religion
Islam Others	154 15	91.1 8.9
Marital status
Married Not married	99 70	58.6 41.4
Education level
Never went to school Class (I –V) Class (VI –X) HSC and above	60 35 54 20	35.5 20.7 32.0 11.8
Occupation
Housewives Working women	131 38	77.5 22.5
Monthly family income (Taka)
Up to 10000 10001-20000 20001-30000 30001-40000 40000 and above	39 52 30 22 26	23.0 30.8 17.8 13.0 15.4

4.2. Socio-demographic characteristics of respondents’ husband

Among the total respondents 99 were married. Educational and occupational data of their husbands are given below.

4.2.1. Education level of the respondents’ husband

Majority of their husbands (54.4%) were educated up to HSC and above level.

4.2.2. Occupation of the respondents’ husband

Only one-fourth of their husbands were in non-paid occupations, which included unemployed and retired.

4.3. Duration of menopause

Histogram shows the distribution of the respondents depending on duration of menopause. Duration of menopause of maximum respondents (56.8%) found between 12 and 50 months and Mean±SD was 56.69±12 months.

4.4. Menopausal symptoms of the respondents

Menopausal symptoms of the respondents were measured by using the Menopause Rating Scale (MRS). In this study it was found that one-fourth of the respondents had hot flushes, 26% respondents had joint and muscular discomfort and only 5.3% had bladder problems. Distribution of these symptoms is summarized in table-4.3.

Table-4.3: Menopausal symptoms of the respondents

n=169

Symptoms	None n (%)	Mild n (%)	Moderate n (%)	Severe n (%)
Hot flushes	26 (15.4)	29(17.2)	71(42.0)	43(25.4)
Heart discomfort	32(18.9)	43(25.4)	70(41.4)	24(14.2)
Sleep problems	44(26)	28(16.6)	73(43.2)	24(14.2)
Depressive mood	25(14.6)	29(17.2)	96(56.6)	19(11.2)
Irritability	21(12.4)	38(22.5)	89(52.7)	21(12.4)
Anxiety	14(8.3)	36(21.3)	89(52.7)	30(17.8)
Physical and mental exhaustion	12(7.1)	31(18.3)	89(52.7)	37(21.9)
Bladder problems	80(47.3)	28(16.6)	52(30.8)	9(5.3)
Joint and muscular discomfort	23(13.6)	29(17.2)	71(42.2)	44(26.0)
Sexual problems	20(20.2)	41(41.4)	33(33.3)	5(5.1)
Dryness of vagina	19(19.2)	36(36.4)	35(35.4)	9(9.1)

4.5.Severity of menopausal symptoms

About 86% of respondents had moderate to severe grade of menopausal symptoms

4.6. Menopausal symptoms and background characteristics of the respondents

4.6.1. Age

Severe grade menopausal symptoms were higher in the age group 50-54 years (57.4%) and Mean±SD score was higher in same age group (17.35±5.18). Findings were not statistically significant.

4.6.2. Marital status

Severe grade of menopausal symptoms and Mean±SD were little higher in married women which were (52.5%) and (16.27±6.45) respectively. This difference was not significant statistically.

4.6.3. Educational status

Severe types of menopausal symptoms were found higher in educational level I-V class (54.3%) and Mean±SD was higher in respondents who never went to school (16.67±5.68) without any significant statistical association.

4.6.4. Occupational status

It was found that severe types of menopausal symptoms were more common in housewives (53.4%) with higher Mean±SD (16.63±5.83). The relationship was statistically significant (?²=9.64; p=0.02)

4.6.5. Duration of menopause

Menopausal symptoms decreased with the increased duration of menopause and there was no statistical significant association.

Table-4.4. Menopausal symptoms and background characteristics

Characteristics	Menopausal symptoms						Test statistics
	None (%)	Mild (%)	Moderate (%)	Severe (%)	Mean score
Age (years)
45-49 50-54 ³ 55	5(10.4) 1(1.9) 3(4.5)	4(8.3) 3(5.6) 8(11.9)	16(33.4) 19(35.2) 25(37.3)	23(47.9) 31(57.4) 31(46.3)	15.38±7.08 17.35±5.18 15.48±6.36		?2=5.99 p=0.425
Marital status
Married Not married	7((7.1) 2(2.9)	5(5.1) 2(2.9.)	35(35.4) 25(35.7)	52(52.5) 33(47.1)	16.27±6.45 15.73±6.01		? 2=5.55 p=0.136
Education
Never went to school Class (I – V) Class (VI – X) HSC and above	1(1.7) 1(2.9) 4(7.4) 3(15.0)	6(10.0) 3(8.6) 6(11.1) 0(0.0)	22(36.7) 12(34.3) 16(29.6) 10(50.0)	31(51.7) 19(54.3) 28(51.9) 7(35.0)	16.67±5.68 16.63±5.83 15.61 ±7.09 14.05±6.45		? 2=10.88 p=0.285
Occupation
House wife Working women	4(3.1) 5(13.2)	9(6.9) 6(15.8)	48(36.6) 12(31.6)	70(53.4) 15(39.5)	16.63±5.83 14.05±7.30		? 2=9.64 p=0.022
Duration of menopause (years)
1-4 5-9 ³10	6(6.3) 2(4.4) 1(3.6)	8(8.3) 4(8.9) 3(10.7)	32(33.3) 15(33.3) 13(46.4)	50(52.1) 24(53.3) 11(39.3)	16.27±6.47 16.07±6.29 15.25±5.58		? 2=2.47 p=0.872

n=169

4.7. Hot flushes and background characteristics of the respondents

4.7.1. Age

Moderate types of hot flushes were more common in the age group 50-54 years (57.4%). Severity of hot flushes increased with increased age. Difference was statistically significant (?²=12.86; p=0.04).

4.7.2. Marital status

Severe types of hot flushes were more common in not married women (30.0%) than the married women (22.2%) but association was not statistically significant.

4.7.3. Education

Respondents who never went to school had more moderate types of hot flushes (55.0%). Severe types were more in educational level I-V class (31.4%) and mild types were more in H