Menopause experiences of women living in karachi pakistan

This chapter presents the background of the study and the significance of the study to nursing. The study purpose, objectives and the study question are also mentioned in this chapter.

Background of the Study

World Health Organization (1990) reported that by the year 2030, about 1.2 billon women in the world will be at least 50 years old. It seems that in future we will have more women of old age. According to National Centre for Health Statistics (2003) women’s life expectancy is now 79.8 years. Women’s life expectancy has increased but their health status and quality of life is in question. To enhance their health status, the National Institute of Health (1991) developed an agenda for women’s health research. The first National Institute of Working Conference (1993) recommended for research on menopause as menopause has become a dominant issue in the women’s health and the quality of life of woman with menopausal symptoms is affected in various ways. In 1999, the National Institute of Health research agenda included attention to diverse population of women. After that, there was a breakthrough in researches on various aspects of menopause such as staging in menopausal transition, physiology, symptoms of menopause and their relationship. This therefore draws attention to the need to conduct more studies on the menopausal experiences of women living in developing countries, because women spend about one-third of their lives in the post menopausal period.

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Menopause is a physiological process, which takes place universally in all women who reach midlife. According to World Health Organization (1990) It is an important event that occurs within a long process of menopausal change, “the period immediately prior to menopause (when the endocrinological, biological, and clinical features of approaching menopause commence) and at least the first year after the menopause” (WHO 1980: 10), in which women move from the reproductive to the post reproductive phase of life as a part of the aging process (Kaufert, 1990; Lock, 1986). Menopause refers to the depletion of ovarian function which leads to stop menstruation and indicates the end of fertility (Lyons & Griffin, 2003). All women in their midlife experience menopause but are difficult to determine what are their perceptions and experience as it is affecting women’s life in various ways.

Women’s experience depends upon their socio-cultural norms and personal knowledge (George, 2002). Kaufert (1996) stated that menopause experience also depends on women’s health at menopause that can be determined by various factors. These factors include: cultural attitudes towards health, disease, and medical treatments, their reproductive histories, the environmental conditions under which they were born and lived, their exposure to disease. According to the bio-cultural perspective, although menopause is defined as a biological event, the experience of this biological event is shaped by physiological and cultural factors (George, 2002).

According to Lock (1986) menopause is of biological and socio-cultural significance; culture provides the ground where values, attitudes, and beliefs about mid-life are transmitted and where the woman attaches meaning to her experiences. Eastern women consider menopause as a natural process and view this life phase more positively as compared to Western women. According to Hafiz and Eden (2007) the differences in attitude between Eastern and Western women can be attributed to more cultural factors than to biological factors. Menopausal women from Asia experience less menopausal symptoms because their social status is raised in older age that the older women in the family are respected as wise matriarchs. They therefore develop positive attitudes toward the incidence of menopause. This is unlike the experience of European and North American women who report more menopausal symptoms and visit health practitioners more frequently. In their experience, the social status of older women in the West declines with age. Therefore, they lose their self-confidence and develop negative attitude.

Women living in rural areas have unique needs associated with menopausal experience (Price, 2007 & 1m, 2008). Geographical and socio- cultural environment is quite different from urban population so they need special attention. Women living in rural areas are often ignored, isolated and have limited health care facilities. Pakistani women lack awareness of menopausal symptoms as well as its long term effects and outcomes but view it as natural and normal process of their life (Malik, 2008; Nusrat, et al, 2008).

Although the literature revealed many key characteristic of menopause experience of women in general, there is limited information about the menopause experience of women living in Pakistan. In Pakistan few quantitative studies have been conducted on age, pattern, characteristics, attitude and symptoms experience of menopausal women under the umbrella of menopause (Malik, 2005 Nusart et al, 2008; wasti 1992; Qazi, 2006; Yahya & Rehman, 2002). These all studies have utilized the survey questionnaire as data collection tool. In my limited search, none study has been conducted yet by using qualitative approach. Therefore, there is a dire need of qualitative approach to develop in-depth insight of menopause experience of women in Pakistan.

Significance of proposed study to Nursing

Life expectancy of women has increased and it seems that it will continue to rise because of the development of modern technology and scientific advancement. Menopause is inevitable for women who live long enough. This study would add knowledge in previously existed knowledge about the menopause experience of women living in Karachi, Pakistan. This study will enable nurses to understand menopausal women in better way and teach them the management of their menopausal symptoms and their effects as well as maintenance of their health status during this phase of life. Nurses would also be able to understand the contributing factors which can influence their experience. Working in different areas in different status, nurses, health workers, and LHV’S nurse practitioner will be able to provide health education according to their socio-cultural context, arrange sessions on sharing the experience and guide them in managing their menopausal symptoms. Nurses who are working in the hospital or other health institute must make them aware of menopausal symptoms of in their middle age so they would be prepare to understand and able to manage their menopause successfully. It would add in previous research on menopausal symptoms experience and can expend the research and may help other in further research if they want to search some other aspects of menopause in the same context/ area of interest to search.

Study Purpose

The study intends to explore the menopause experience of women living in Karachi, Pakistan.

Study Objectives

The study objectives include: Firstly, to gain insight about the perceptions of women related to menopause. Secondly, is to find out the impact of menopause on women life. Thirdly, to explore the challenges menopausal women face and finally, to find out the strategies used to manage the challenges.

Study Question

What is the menopause experience of women living in Karachi, Pakistan?

CHAPTER TWO

Literature Review

Menopause is naturally occurring process which all women throughout the world experience in their midlife. Menopause refers as the depletion of ovarian function which leads to cessation of menstruation and indicates the end of fertility (Lyons & Griffin 2003). This section provides an overview of the literature reviewed, relevant to the study and highlights the research carried out on this topic. The forth coming literature is divided into different sections. First, is the physiology of human menstrual cycle and mechanism initiating menopause. Second, is the historical development of research support on menopause? Third, are the concepts or meanings of menopause? Fourth, is the factors affecting and influencing the menopause experience and finally, the comparison of studies undertaken in USA and South Asia.

Physiology of Human Menstrual Cycle and Mechanism Initiating Menopause

There are four (4) events involving in the hypothalamic pituitary-ovarian axis that control the human menstrual cycle: First, the secretion of follicle-stimulating hormone (FSH), responsible for the development of ovarian follicles and production of estradiol (Hiller, Reichert & Van 1981). Throughout the menstrual cycle, estrogen maintains low gonadotrophin levels via its negative feedback effect on hypothalamic gonadotrophin releasing hormones and consequently lutenizing hormone (LH) and FSH secretion. (Yen,Tsai,Vandenberg & Rebar 1972). Second, the FSH-induced increase in ovarian estrogen secretion to trigger an LH surge that is called positive feedback (Young & Jaffe, 1976). Third, is the LH surge, a hypothalamic – pituitary response to the estrogen stimulus? This positive feedback response of estrogen on LH secretion has been used as a test of hypothalamic – pituitary function (Weiss, Nachtigall & Ganguly, 1976). Final event is ovulation and leutinization of the follicles, triggered by LH surge, forming a corpus luteum. This is an ovarian response that results in progestrone secretion necessary for the establishment of a pregnancy (Vande et al, 1970).

The onset of human menopause is thought to be caused by ovarian failure and follicles depletion. However, clinical symptoms and some of the recent data on menopausal woman suggest central nervous system involvement. (Weiss et al, 2004). The Study of Women’s Health across the Nation (SWAN) was conducted to determine if the modification of hypothalamic-pituitary response to estrogen feedback mechanism occur in older reproductive-age women as a mechanism of onset of menopause. Three groups of women were studied who had estrogen increased and on LH surge, estrogen increased without on LH surge and neither estrogen increases on LH surge.

Anovulatory cycles with high estrogen were frequent in older reproductive age women and there was an evidence of failure of the estrogen – positive feedback on LH Secretion to initiate and stimulate ovulation. In anovulatory cycles follicular estrogen levels did not lower LH secretion as it was in younger reproductive age, there was decreased estrogen-negative feedback on LH secretion. It was concluded that there was hypothalamic-Pituitary insensitivity to estrogen, in aging perimenopausal women.

Historical Development of Research Support on Menopause

In 1993, the first National Institute of working conference recommended for research on menopause and in 1999, NIH research agenda included attention to diverse population of women. Seatle Midlife Women’s Health Study was a longitudinal study conducted from 1990 – 2000 to study the FSH by Menopausal transition stages early, middle and late transition by the use of menstrual cycle calendar. Comparison of reproductive age and peri-menopausal women’s cycles. Urinary estron and FSH level by menopausal transition stages late reproductive, early menopause transition and post menopause transition.

Study of Women’s Health Across the Nation (SWAN) began in September 1994. The purpose of the study was to describe the chronology, the biological and psycho-social characteristics of menopausal transition and the other purpose was to describe the effects of this transition on health and risk factors for age related chronic conditions. The emphases placed on multiethnic samples and community or population based samples.

Swan study included daily hormone study over multiple years and annuals blood draws, interview, clinical exams and questionnaire. Multiple ethnic groups of women Africans, Chines, Japnese, Hispanis and White American were included in this study.

The stages of reproductive aging work shop (STRAW) was held in Park city USA in 2001. The purpose of this workshop was to develop the staging system for the menopause transition. The benefits of this system are that the researches and clinician can compare cases and data across studies. Women would understand the timing and duration of the transition. This system has seven stages. Five precede and two follow the final menstrual period. Stages from -5 to -3 encompass the Reproductive Interval; stages from -2 to -1 the Menopausal transition and +1 to +2 the post Menopause (Soules et al, 2001).

March (2005) A conference on management of menopause related symptoms was held by office of medical applications of research in USA to understand the symptoms and their correlation with menopause transition stage. Seatle midlife women’s health study on charting the course of the natural transition to menopause for a population based sample of 35 – 55 years old white, Asian and African, American women ( n=375) in longitudinal study begun in 1990 and followed until 2006. Women provided daily health diary recording for 3 days per month. Monthly early am urine sample for endocrine analyses and annual health update symptoms rated from 0 (absent) to 4 (extreme).

It was estimated that severity of hot flashes increased after the last menstrual period (FMP).There was an association between hormonal changes during menopause transition and the symptoms experienced by the women such as: hot flashes, sleep disturbance, depressed mood, anxiety, fatigue and vaginal dryness. There were some other factors associated with these symptoms severity.

As physiology change so there are chances of developing the medical problems. SWAN studies ruled out the other diseases associated with menopause such as cardiovascular disease, osteoporoses. In the period of late and early menopausal transition there may be the the chances that the lumen size of the carotid artery becomes larger (Wikdman et al, 2008).Women experience a high incidence of depressed mood during late menopausal transition (Bromberger, 2007 ; woods et al, 2008).

Concepts or Meanings of Menopause

Menopause is a complex and significant phase of life that affects women’s life in different ways globally. It is a life event that leads to physical as well as emotional challenges (George 2002; Lyons & Griffen 2003). One can realize it’s impact on women’s life as was identified by McCrea (1983) stated that in Victorian era menopausal women were used to view as aging women, with a decomposing body and an evil mind suffering from foolishness.

All women experience menopause between the ages of 48 and 55 years (George, 2001), but it is difficult to determine how it is perceived by women. What does it mean to her? There is a dilemma attached to it whether it is consider as medical problem or as a life transition (James & Deborah, 1997; Lyons & Griffen, 2003). There are four main meanings or notions about menopause. First, is the biological or biomedical? Second, is the developmental and natural event? Third feminist notion, as natural female process and fourth, post modern which is related to physiological, social and cultural dimensions. (Gosden, 1985).

A biologic definition of menopause refers to permanent cessations of menstruation resulting from loss of ovarian follicular activities and indicates the end of fertility. (Gosden1985). The last menstrual flow is the biologic marker that refers to a woman transition from a productive to non productive phase. Symptoms which are experienced by the women such as: hot flashes, perspiration, palpitation, vaginal dryness, sleep disturbance, forgetfulness, difficulty in concentrating and irritability also describes the menopause. Another aspect of biologic or biomedical view is the disease orientation to menopause which supports the use of hormonal replacement therapy (George, 2002). Changes in physiology seem to be experienced as symptoms that may require medical treatment. Until recently menopause has been viewed from a medical perspective (James & Deborah, 1997). It seems that physician view menopause as a disease that must be treated.

Menopause as a developmental and natural event considers as a part of women’s life and taken to be normal. Menopause is often stressful but it doesn’t mean that it is a disease. It should be perceived as a part of the normal developmental cycle.

Life expectancy of women has increased now which indicates that menopause will now be seen as a normal event not a medical condition but as it is associated with specific health risks (osteoporoses and cardiac diseases) it is likely that physicians will continue to treat it and its symptoms.

Menopause as a feminist notion that emphasizes that it is a natural female process. It can be taken as a change. If a woman understands this period as a change in her life pattern and she would try to adjust and cope with it (Lyons & Griffen, 2003).

Menopause as post modern notion believes that it is related to physiological, social and cultural dimensions. The meaning of menopause may be positive or negative it depends on the woman’s culture, the status of the women in the society as well as the physiological change that occurred as a result of menopause. Lyons and Griffen (2003) introduced another meaning and that is “confusing” and it is between the natural and disease construction. A woman has uncertainty about the menopause and it is the result of lack of knowledge and understanding. If menopause as taken “confusing” it produces anxiety and uncertainty which further complicate the complexity of menopause.

Surgical meaning of menopause refers to the menopause as a result of surgical intervention (oophractomy and or hysterectomy) but the symptoms are same as natural menopause, however, the onset is abrupt and symptoms are more severe as compared to natural menopause moreover, physical and psychological symptoms are due to sudden hormonal change (Park 2005).

Menopause may be viewed by women as natural or medical event; it may be confusing or challenging. The way it is perceived ultimately affects woman’s experience. There are many factors which can be attributed in the menopause experienced by the women.

Factors Affecting or Influencing Menopause experience

Menopause is a bio-cultural experience therefore bio-cultural factor such as environment, diet, fertility and genetic differences may be involved in the variations of menopausal experience (Beyene, 1986). Furthermore James and Deborah (1997) explained that a woman’s culture teaches her how she should respond to this event in her life. If a woman’s role is child bearing by her culture then she perceives her-self unimportant as menopause means the end of her role. George (2002) asserted that the menopause and how women experience it depends on her cultural norms, social influences and personal knowledge about menopause which influence the woman’s ability to cope with the menopausal period. Elliot, Berman and Kim (2005) added culture is embedded in all aspects of one’s life and affects one’s ideas, beliefs and ultimately affects on the menopause experiences. Ellen (2005) stated that women with infertility problem experiences menopause as normal and natural event after futile struggle for so long to become productive. Infertility was an abnormal event as it interfered with normal phase in life and menopause for them is a normal event that is supposed to happen so they take it positively.

It is believed that each woman experiences the menopausal symptoms in a same way; however this is not the case. Avis (2002), Flint (1975), and Yahyeh and Rehan (2006) asserted that cultural differences also affect menopausal symptoms experience. The pattern and frequency of menopausal symptoms vary from culture to culture. Avis (2002) conducted a large cross sectional study for women aged 40-55 years across racial or ethnic groups of women in the United States for the comparison of menopausal symptoms. Result showed that across all five groups two consistent factors emerged. One was hot flashes and night sweats and the other psychological and psychosomatic symptoms. Caucasian women reported more psychosomatic symptoms; African American women reported more vasomotor symptoms. The pattern of finding argues against a universal menopausal symptoms syndrome consisting of vasomotor and psychological symptoms. On the other hand Im, Liu, Dormire, and Chee (2008) identified that white women believe that generational and life style differences are much more important than ethnic differences in menopausal symptoms experience.

In a study of Indian women, Flint (1975) found that few women had any problem other than cycle changes. Lock (1986) found that Japanese Women did not have depression and also having low rates in vasomotor symptoms as compare to western culture women.

In a cross cultural comparison of menopausal symptoms Avis (1993) reported the rate of almost every symptoms were lower in the Japanese than US and Canadian women. Price, Storey, and Lake (2007) identified that living in isolated environment and lack of social support system; women experienced more severe menopausal symptoms and experienced the loss of control on physical as well as psychological symptoms.

It is conclude that the experience of menopausal symptoms is not same for each and every woman. They are influenced by one’s socio-cultural back ground (environment, life style, knowledge, values, beliefs and the meaning of menopause perceived). It also affects the overall menopause experience of women. If the meaning of menopause taken negatively, the women will have more intense symptoms and face difficulty in managing herself as well as seek for medical treatment and experience menopause as a threat.

Comparison of Researches: USA and South Asia.

George (2002) conducted a study to explore the experiences of American women from diverse ethnic and socio-cultural environment. He found that the experiences of American women were not similar; they were all unique in their experiences. Some of them were having high intensity of menopausal symptoms but some did not experience any menopausal symptoms, some of them were confused as they were unaware of what to expect. Some experienced depression but some were feelings of relief from child bearing and monthly periods. Some were looking forward to future. In another online study of white midlife women Im, Liu, Dormire, and Chee (2008) identified that white women believe that generational and life style differences are much more important than ethnic differences in menopausal symptoms experience they are optimistic and try to cope with the symptoms. Women needed assistance with the menopause symptoms and were not satisfied with the guidance of the physicians use humor as coping strategy for menopause to increase their inner strength and motivate them to go through the hardship.

Price, Storey, and Lake (2007) conducted a study on experiences of women living in a rural area of Canada. Researchers identified that women considered it as a change of life, and showed high concern about their general health and the changes their bodies under going. The women described the need to understand the intensity of menopausal symptoms (physical, psychological and social), including changes to their physical and mental well being. They need to receive reliable information. Menopause had significant impact on their personal relationships as they were unable to share their experiences with their husbands. Their coping strategies were social support and humor.

Elliott, Berman, and Kim (2002) conducted a study on Korean Canadian women on menopause experiences. He found that they view menopause as a natural process and wanted to be fully aware about all aspects of menopause in order to control and cope with this phase of life. They were having difficulties in communication with health care professionals. They were reluctant to share their experiences with their husbands but they expressed the need to share their feelings with someone.

Hafiz, Liu and Eden (2007) conducted a study on the experiences of menopause among Indian women. They identified that because of their positive socio-cultural ideas and attitude towards menopause they were not concerned about becoming menopausal and believe that it is a natural event same as birth and death. They experienced more physical and psychological symptoms rather than vasomotor (hot flashes and might sweat). He revealed that physical and psychological symptoms were higher in Asian women.

Researches in Pakistan

In Pakistan few quantitative studies have been conducted on age, pattern, and characteristics, attitude and symptoms experience of menopausal women (Malik, 2005 Nusart et al, 2008; wasti 1992; Qazi, 2006; Yahya & Rehman, 2002). No qualitative studies have been conducted on menopause experience yet.

Wasti et al (1993) conducted a study on the characteristics of menopause in three socio-economic urban groups in Karachi. The total samples size was 750 menopausal women. He found one in five women were symptomatic to poorest group but one in two the other groups. He found that fewer women had menopausal symptoms in his study but he admitted or hypothesized that menopausal problem will be most probably increase as life expectancy of women is increasing. He found mean age of natural menopause was 47 years of age.

Yahya and Rehan (2002) conducted a study on age; pattern and symptom of menopause among rural women of Lahore will sample size of 130 women from 20 villages. He found mean age at menopause was 49 ±3. 6 years. Moreover the common symptoms were lethargy 56.4%) forget fullness (57.7%) urinary symptoms (56.2%) agitation (50.8%) depression (38.5%) insomnia (38.5%) ht flushes (36.2%) and dysparunea (16.9%). He concluded that the mean age of menopause was lower than the reported for Caucasian, but similar to Africa and South America but higher than Iran, Egypt and UAE. The frequency of symptoms was lower than observed among Caucasians, he suggested further studies on local buologies and understanding the socio cultural basis of these differences.

Malik (2005) conducted a study on knowledge, attitude towards menopause and Hormonal Replacement Therapy (HRT) among postmenopausal women in Karachi. The sample size was 102 post menopausal women. She found mean age at menopause was 147.4±3 years. She found most of the respondent had positive attitude towards menopause and consider menopause as natural event lacked sufficient knowledge our menopause and HRT.

Qazi (2006) conducted a study on age, pattern, symptoms and associated problems among urban population of Hyderabad. Sample size was 800 menopause women. He found mean age at menopause was 47.16. the marked climacteric symptoms were low backache headache, tiredness, lump pain, sleep disturbance and might swats were common menopause associated problems include Ischemic Heart Disease, Hypertension, Diabetes mellitus, post menopause that the symptoms and problems were different from other studies reported with in the country and abroad which may revealed socio cultural and dietary differences.

Nusrat et al (2008) conducted a study on knowledge attitude and experience of menopause. The sample size was 863 menopausal women. She concluded that majority women consider menopause as natural event and have positive attitude but majority of the women were unaware of menopausal symptoms and health effects, the bothered by symptom but did not sought for treatment.

The age at natural menopause according to Pakistani studies is between 45-51 years; mean age is 48 years (Malik, 2008, Qazi, 2006; Yahya & Rehan, 2006). Some of the findings were similar in the studies which have been conducted in Pakistan. Pakistani women consider menopause as natural and normal phase of life and aging process. They have positive attitude to words menopause (Malik, 2005; Nusart et al, 2008; Yahya & Rehman, 2002). These findings are similar with the findings of studies have been conducted in other Eastern countries women such as India, China, and Korea. The other finding that the Pakistani women are not fully aware of the menopausal symptoms and its health implication or its long term consequences on quality of life (Malik, 2008. Nusrat et al, 2008; Yahya & Rehan, 2006). Majority of the women bothered with the menopause symptoms but because of positive attitude, poverty, and due to lack of awareness they do not go for treatment or consultation. Malik, 2008; Nusrat et al, 2008).

Qazi (2006) identified many differences in his study especially in the prevalence of symptoms reported with in the country and assumed that these are because of socio-cultural and diet differences. In rural areas of Lahore, Yahyeh and Rehan (2006) found the prevalence of various symptoms comparatively lower than other Caucasian. Researcher suggested the need for studying local biology’s and understanding of socio-cultural bases of these differences.

Summary of the Literature

The literature revealed important information about the physiology as well as the initiation process of this phenomenon. The various concepts and meanings perceived by different school of thoughts. The historical development in the research on menopause is also addressed. Factors which are closely involved in influencing menopause experience as well studies conducted on this topic are also highlighted. The Eastern women conceptualize menopause as natural process that’s why they have positive attitude towards it as compare to Western women. They bothered by menopause symptoms but try to cope with it positively. In Pakistan quantitative studies have been conducted on this topic but this approach did not provide insight in to a women’s understanding the need of qualitative research is required to explore the women experience related to this phenomenon. (George, 2002).

CHAPTER THREE

Study Design and Methodology

This chapter focuses on the approach to conduct this study, the study design and rationale of the design, the study population, study setting as well as sample and sampling. Data making, data management, data analysis, study rigor and the study limitations will also be the part of this chapter.

Study Design

The study design which is selected for this study is qualitative descriptive-exploratory. According to Polit and Beck (2008) qualitative approach involves naturalistic pattern. Naturalistic methods of inquiry deal with the experiences of human complexity by exploring it directly. It emphasizes on understanding the human experience as it is lived. Qualitative study required for in-depth and rich information to understand the phenomenon. Furthermore Holloway and wheeler (2002) concluded that qualitative research is an objective way to gain knowledge about the subjective and holistic nature of human. Burns and Grove (2007) stated that the purpose of exploratory study is to investigate a specific concept about which little is known. It emphasizes on identification of factors related to a phenomenon of interest. As this study aims to explore the menopause experience, which is lived experience and there would not be one reality as each women experience would be different. Therefore a qualitative exploratory descriptive design is best suited to this study.

Study Population

The study population would be all women who are in their menopausal period, coming to Obstetric and Gynecologist’s outpatient department of Pakistan Naval Ship hospital, Karachi. The target population will be all the menopausal women who will meet the inclusion criteria, will be coming to Obstetrics and Gynecology OPD.

Setting

Pakistan Naval Ship hospital, Karachi will be selected as data collection site. Obstetric and Gynecologist’s OPD will be utilized for this purpose. This hospital was established in 1963. It is classified as a class “A” Pakistan Navy’s hospital. The total bed stren