Women ' s experience and attitudes towards menopause and health : descriptive research

Introduction: The physiological changes in hormonal levels occurring during perimenopause and postmenopause may affect the health of women. The purpose of the research was to explore the views and attitudes of women of this stage towards menopause, health, healthy lifestyle and some aspects of information regarding menopause. Methods: The study was based on a quantitative and qualitative approach. A semi-structured questionnaire (Cronbach α = 0.813) was used as a research instrument. The open question was interpreted by a qualitative method. A random systematic sample consisted of one hundred female patients, aged 45 to 60 years, attending a private healthcare institution. The survey was conducted in October 2014. The data collected were processed with the software Microsoft Excel and SPSS version 20.0. Results: The self-reported health status of the respondents was good (57.3 %) or very good (22.3 %). The most commonly cited symptoms included hot flushes and night sweats (x = 2.73), sleep problems (x = 2.8), and mental and physical exhaustion (x = 2.70). Information from nurses was never sought by 57.6 % and occasionally by 9.8 % of the respondents, although the interviewees expressed the need for more comprehensive information on the subject. The identified subcategories include a positive attitude and self-confidence, support of the environment, consumer health information and healthy lifestyle. Discussion and conclusion: The research participants have a positive attitude to health, they are aware that there is much they can do to maintain and improve their health. As they also expressed the need to be better informed, the scope of nurses' work in referential out-patient clinics may be extended to menopausal counselling. However, more research on this topic needs to be undertaken.


Introduction
Health is one of the fundamental elements of our life as it satisfies the need for survival and quality of life (Štern, 2007).In the last decades, several experts have addressed the problems occurring during the perimenopause and postmenopause stages, which may significantly impact on the quality of women's life (Meden-Vrtovec, 2007).Meden-Vrtovec (2007) raises questions about the treatment of menopause women, and whether medical workers are willing to recognise and help alleviate the ensuing physical and psychological symptoms.The changes occur at different levels and are reflected in women' psychological and physical well-being.It is therefore suggested that women are treated as holistic entities, taking into consideration the interdependency and complexity of their parts (Mlakar, 2007).Time period preceding and following menopause is called climacterium.According to Meden-Vrtovec (2002), the phenomenon and duration of climacterium is divided into four stages, i.e. premenopause, when the psychological and somatic changes may be present several years prior to the onset of menopause; perimenopause; menopause, characterised by permanent cessation of menstrual periods; and postmenopause.Hereinafter, the four stages will be referred to as perimenopause (including premenopause and perimenopause) and menopause (including menopause and postmenopause).
Menopause is the time in a woman's life when she is faced with a number of losses, namely, fertility decline, changed physical appearance, change in libido and sex drive, sexual activity and satisfaction.In this period of life, a woman begins to reflect upon the transient nature of her being, as menopause is perceived as a signpost of change, aging or dying (Vigeta, et al., 2012).Menopausal symptoms experienced by women decrease the quality of their life (Borko & Žegura, 2006, p. 113), but there is increasing evidence that life-style protective factors, such as nutrition and physical activity, have a profound modifying effect on midlife health (Lainščak, et al., 2005;Labrinoudaki, et al., 2013).Marn Radoš and Šćepanović (2014) emphasise the importance of health education about adequate forms of physical activity (e.g. as power walking, running or walking up the stairs, etc.), which is accessible to the entire targeted population, irrespective of their social status.It is of key importance that health professionals explain to women which physical and psychological changes occur during menopause and what they can do to alleviate the symptoms.They may counsel on healthy lifestyle, with special emphasis on nutrition and physical activity (Petkovič, 2007).McCloskey (2012) claims that health workers' knowledge of the concept and the stages of a menopausal transition is still deficient.Cumming and collegues (2015) report that health professionals continue to let their patients down with poor provision of information, inaccurate or wrong information, or lack of access to adequate health care.The cost of this is women living with preventable sequelae associated with the menopausal transition with a consequent adverse impact on health and the health economy.According to Mander (2012), women should be advised on what they should do or avoid in terms of lifestyle and diet to improve their quality of life.Franić (2008) suggests more activities on the primary level of health care, targeted especially to young women in order to prevent problems in later years.The British Menopause Society Council claims that the provision of a simple health check of all women at the age of 45 years would provide an excellent opportunity that would serve as a screening as well as an educational visit at which balanced information about appropriate treatments and lifestyle changes in natural and premature menopause should be given to empower women to make an informed choice (BMSC, 2011).

Aims and objectives
The aim of the study was to explore the women's views and attitudes towards perimenopause and menopause, health and healthy lifestyle as well some aspects of information related to the issue.The following research questions were set: How do women in perimenopause and menopause − rate their general health?How do women self-assess their menopausal − symptoms according to the level of intensity?
Where do women obtain most information related − to menopause and health?

Methods
A non-experimental descriptive research method was applied.

Description of the research instrument
A semi-structured questionnaire was used as a research instrument for data collection.The questionnaire was designed on the basis of professional literature review (Borko & Žegura, 2006;Meden-Vrtovec, 2007;Mlakar, 2007), and partly on the validated Menopause Rating Scale (MRS) developed in Germany (Heinemann, et al., 2004).The original questionnaire was translated into 25 languages, but it was not available in the Slovene language.The questionnaire used in the study was translated from the English language and tested in a pilot study including seven interviewees.It differs from the original version in additional four statements.It is composed of 43 closed-ended, two open-ended, sixteen multiple-choice questions and 27 statements.In 11 questions the MRS was used to evaluate the severity of symptoms/complaints.The score increases point by point with increasing severity of subjectively perceived symptoms in each of the items (severity 0none, severity 1 -mild, severity 2 -moderate, severity 3 -severe, severity 4 -very severe).In 16 questions the Likert five-point scale with fixed choice response formats was used to measure the attitudes or opinion statements.Each of the five responses was attributed a numerical value used to measure the attitude under investigation (1-Strongly agree, 2-Agree, 3-Undecided, 4-Disagree, 5-Strongly Disagree).The first part of the questionnaire included nine demographic questions, and the main part enquired about the respondents' attitudes towards menopausal changes and symptoms experienced, the self-assessed lifestyle and bad habits, health and accessibility of information related to menopause.The Cronbach's alpha coefficient for the whole scale was 0.813, which indicates a high reliability of the instrument (Cencič, 2009).

Description of the research sample
For the purposes of the study, a random systematic sample was employed.It consisted of 100 women, aged 45-60 years, who had their chosen general practitioner in a private concession clinic, which provides preventive care and curative services for adult population (e.g.diagnostic procedures and treatment of diseases and injuries).DDM 3.0 computer programme was used to select every fifth woman from the alphabet list, satisfying the inclusion criteria (1 : 4 ratio).The sample consisted of 120 participants, which presents 20 % of the population registered in this clinic.The response rate was 83 % (n = 100).The majority of women belonged to the age group of 50-54 years (n = 41, 41.7 %), followed by the age group of 45-49 years (n = 24, 25.7 %) and the age group of 55 years and above (n = 35, 32.5 %).Most of the respondents completed university education (n = 38, 38.7 %) and only 3 (1.2%) had primary education or less.Most of the respondents were employed (n = 83, 81.8 %), and the remaining ones were unemployed (n = 7, 10.1 %) or retired (n = 9, 7 %).One of the respondents did not answer this question.
The majority of women assessed their socio-economic status as satisfactory (n = 65, 63.1 %), 9 (10.4 %) respondents reported that they earn even more than they need, and 25 (25.8 %) respondents were not satisfied with their income.One respondent did not answer this question.
According to the stages of menopause as defined by Meden-Vrtovec (2002), the sample consisted of 37 (40.1 %) women in premenopause or perimenopause and 49 (44.5 %) women in menopause or postmenopause; 14 respondents did not answer this question.

Description of the research procedure and data analysis
The research was conducted at the primary level of health care, that is, in primary care in the family out-patient clinic.The questionnaires with a request to participate in the study were sent to the selected women's home address in a stamped reply envelope.The purpose of the study was fully explained.The participation was anonymous and voluntary.The study was conducted in accordance with the adopted ethical principles.The sampling took place in October 2014.The data collected were analysed using Microsoft Excel and SPSS version 20.0 (SPSS Inc., Chicago, IL).The sociodemographic data were analysed by descriptive statistics.The frequencies, percentages, arithmetic means and standard deviations were calculated for statistical variables.The t-test was used to determine the statistical significant differences between women in perimenopause and menopause and the Pearson's correlation coefficient was employed to measure the statistical relationship between the two variables.The statistical significance (i.e. the p-value) was set at p < 0.05.
More than half of the respondents answered the open-ended question.The texts were analysed with a qualitative approach and the meaning from the content of text data was interpreted by a summative content analysis according to the given category of experiencing menopause (Hsieh & Shannon, 2005).The analysis started with a theory or relevant research findings as guidance for initial codes.It involved counting and comparisons, usually of keywords or phrases, joined in groups and subgroups, followed by the interpretation of the underlying context (Hsieh & Shannon, 2005).

Results
The study participants rated their overall health as good (n = 58 %), very good (n = 12 %), fair (n = 22 %), poor (n = 3 %) and very poor (n = 2 %).Three respondents did not answer this question.The respondents were requested to report the presence of any chronic non-communicable disease, such as arterial hypertension, diabetes, asthma, etc. Absence of any of the above diseases was reported by 69 (70.4 %) interviewees, 1 (1.9 %) respondent was not aware of the presence of any disease, and 29 (26.4 %) interviewees suffered from at least one of these diseases.
The study also aimed to establish the respondents' attitudes towards healthy lifestyle.The analysis of survey results shows that 12 (12.1 %) women are extremely concerned about their health, 86 (86.9 %) claimed that there are many things they can do themselves to maintain or improve their health, 51 (51.5 %) respondents regularly attend preventive examinations /screening tests, 30 (30.3 %) reported that they try to achieve and maintain a healthy weight, 41 (41.4 %) participants reported that they regularly perform physical exercises and maintain their physical fitness, 30 (30.3 %) respondents pay particular notice to regular meals and balanced diet.A smaller number of respondents, however, reported insufficient physical activity (n = 35, 35.4 %), unhealthy diet and irregular meals (n = 13, 13.1 %), and 3 (3 %) respondents pay no attention to their health.
The Likert five-point scale with fixed choice response formats was used to measure the attitudes or opinion statements regarding menopause.According to the median values achieved (M = 3), it can be concluded that the respondents had some difficulty to accept physical changes associated with aging, they experienced fatigue and exhaustion due to insomnia and they were reluctant to use hormone replacement therapy (HRT) due to possible adverse effects.In part, they also felt liberated by the fact that they no longer need to worry about protection and contraception (M = 3).The menopausal changes, including the inability to bear children, did not affect women's perception of their own femininity (M = 1).The results show that the respondents did not agree with the majority of the remaining statements (M = 2).The attitudes towards hormone replacement therapy differed among the respondents.Thirteen respondents (13.7 %) were satisfied or very satisfied with the results of the HRT, 46 (48.9 %) respondents expressed their reservations about HRT for fear of possible adverse effects, and 25 (26 %) respondents believed that their menopauserelated knowledge was insufficient.
The internationally accepted MRS was used to measure the severity of menopausal symptoms over time.The severity of symptoms was evaluated on a five-point self-administered scale.The score increases point by point with increasing severity of subjectively perceived symptoms (from none to very severe).The mean values obtained (M = 3) indicate that women most commonly suffered from hot flushes and episodes of sweating, sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early), physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness).Other symptoms were only moderate (M = 2).Least commonly reported symptoms included bladder problems (difficulty in urinating, increased need to urinate, urinary incontinence) and dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse).
Table 1 presents statistically significant differences in the participants' perceived level of severity of perimenopausal and menopausal symptoms.The study results show that women in menopause experience statistically significantly more sexual problems (p = 0.015) than women in postmenopause.These symptoms include waned sexual desire or interest, decreased sexual activity and satisfaction.Women in menopause also statistically significantly more frequently report dryness of vagina (p = 0.010) and joint and muscular discomfort (p = 0.018).
The correlation was calculated between the values obtained for the symptoms experienced by women in perimenopause and the women in menopause.Highlighted are the most important findings, i.e. those with correlation coefficient of more than 0.5.As a result of mood swings, the interviewees often feel misunderstood and find it difficult to talk about their problems (r = 0.508, p < 0.001).They feel that their self-image has changed (r = 0.577, p < 0.001).The age-related changes (dry skin, sagging breasts) have a negative impact on their self-esteem and feelings of self-worth (r = 0.680, p < 0.001).The interviewees also admit that they do not have enough knowledge to address the menopausal symptoms (r = 0.534, p < 0.001).They report that their world has been turned upside down, they feel less feminine with the end of their fertile period (r = 0.532, p < 0.001), and that they have not been properly prepared for menopause (r = 0.558, p < 0.001).The women who described their sensations of heart discomfort (suddenly I become aware of my heart beat, heart skipping and heart racing), also experienced mood disorders (I am feeling down, sad, on the verge of tears, I feel a lack of motivation and drive, I suffer from mood swings) (r = 0.549, p < 0.001).These feelings are often accompanied by irritability (I feel nervous, tense and aggressive) (r = 0.843, p < 0.001) and anxiety (inner restlessness, feeling panicky) (r = 0.747, p < 0.001).Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) is statistically correlated with mood disorders (r = 0.647, p < 0.001).
As shown in Table 2, the interviewees most frequently, however occasionally, sought information about menopause in the printed media (newspapers, magazines) (M = 2), on the internet (generally) (M = 2), and from their gynaecologist (M = 2).They hardly ever discussed menopause and menopause-related symptoms with their general physician (M = 4) and never with a nurse in an out-patient clinic.
The open-ended question was included in order to give the respondents an opportunity to express their subjective opinions and views on the perimenopause and menopause transition periods.The question was answered by 63 (61.9 %) respondents.Nine coding categories were derived from the text data, on the basis of which four subcategories were designed (positive attitude and self- confidence; healthy lifestyle, awareness/information and support), which are shown in Table 3.The latter includes the codes, further separated into subcategories and a category, with some statements or phrases, their codes and the frequency of statements linked into individual codes.The participants most frequently stated that the period of perimenopause and menopause should be accepted as a natural stage of life (33.4%), 7.2 % claimed that this period is replete with worries, fears and insecurity, 5.4 % emphasised the importance of positive approach to menopause and self-care, 6 % stressed the importance of a healthy diet, 5.7 % expressed the need for more information on this gradual life transition, 2.9 % were not aware of menopausal symptoms, 3.8 % assigned special importance to discussing the problems, 1.7 % to the support of their family and friends, and 3.1 % underlined the importance of physical activity during this period.

Discussion
The study addresses the menopause, with its positive sides, and a series of symptoms due to physiologic hormonal changes in this transitional period in women's life.Menopause is a natural and universal event of the human female life cycle.However, it is a period that is different for each individual, depending on their attitude towards themselves, menopause and health.Kopčavar Guček and Franić (2008) stated that nowadays, most women spend more than one-third of their lives in menopause due to longer overall survival and greater life expectancy.Women, on average, live longer than men and they will therefore enjoy fewer years of healthy life as they will experience longer periods of poor health (Vertot, 2010).The majority of interviewees rate their current health as good, with no identified chronic diseases.The study findings indicate that women are aware of what they should do or avoid in terms of lifestyle and diet to improve their health condition.Most of them regularly attend preventive examinations/screening tests and one third of them engage in regular physical activity even more than three times per week.It was established that only one third of the participants attend to their body weight and follow a healthy, balanced diet.Sveinsdóttir and Ólafsson (2006) found that Islandic women generally have a positive attitude towards menopause and consider it a natural transition which can not be prevented.The results of the present study indicate that the participants were most commonly saddened by the signs of aging, they felt tired and exhausted due to sleep problems.They had negative attitudes to hormone replacement therapy being aware of their possible side effects, but expressed satisfaction that they no longer needed to fear unwanted pregnancy.Some other authors (Črnigoj & Prosen, 2016) also claim that spontaneous sexual activity influences the quality of life and the relationship of a couple.Women in menopause may suffer from mood swings, one of the most common symptoms of menopause caused by hormonal fluctuations.The inappropriate or disproportionate emotional reaction to its cause or trigger is often misunderstood and therefore the study participants expressed their reluctance to discuss this issue.The study also raised the issue of women's changed self-image and adversely affected confidence due to the signs of aging (dry skin, sagging breasts).The respondents (25 %) reported they did not know enough about appropriate health and lifestyle interventions to alleviate their menopausal problems.
The participants reported that their world was turned upside down and they were not adequately prepared for this natural process of development.The evidence presented shows that the interviewed women have a need to discuss their menopausal complaints and that they need more health education and psychological support.One fourth of the respondents admitted that they do not know enough about menopause symptom management.The results of the present study related to the HRT, alternative therapies and sexual health are in line with the findings obtained by Cumming and collegues (2007), which indicate that the patients are let down with poor provision of information, inaccurate or wrong information, or access to the right care.It seems appropriate to provide information about women's health at all levels of health care, especially at a primary level, which is most widely accessible.The study research reveals that the respondents most frequently sought menopause-related information in newspapers and magazines, on the internet and from their gynaecologist.It is interesting to note that more than half of the respondents never turned to nurses in an out-patient clinic for information or advice.An action needs to be taken in order to strengthen the advisory role of nurses who are autonomous health professionals with competences to provide also health counselling, health promotion and health education (Železnik, et al., 2008).The study conducted by Pepić (2012) reveals that only 4.5 % of the participants received health education related to menopause and climacterium from their gynaecologist and only 2.6 % from nurses.Similar results were obtained in the study conducted among Islandic menopause women (Sveinsdóttir & Ólafsson, 2006).The participants of the present study confirmed that the information obtained (from other sources) was helpful.One of the reasons why women do not seek information in health institutions could be their denial of menopausal symptoms or because they want them keep hidden (Sergeant, 2015).
It was established that the respondents' most frequently cited symptoms include hot flushes, sweating, sleep disorders, and physical and mental exhaustion.Among the less frequent symptoms were heart discomfort, depressive mood with mood swings, irritability, and joint and muscular discomfort.The present study produced results which corroborate the findings of previous research (Sveinsdóttir & Ólafsson, 2006;Chedraui, et al., 2007), where the same research instrument (MRS) was used.The studies conducted in Equador (Chedraui, et al., 2007) and Iceland (Sveinsdóttir & Ólafsson, 2006) reveal that the most frequent symptoms reported by the studied population were pains in the muscles and joints, mood swings, sexual problems, hot flushes and sleep disorders.
Brown and collegues (2015) investigated the psychological distress during the menopause transition and also evaluated evidence on the relationship between menopausal factors (stage and symptoms) and indices of positive well-being.They concluded that little is known about the experience of positive well-being at this time and that positive well-being may be available for use as a resilience factor that women can draw on to meet the challenges that midlife presents.One third of the participants of the present study also highlighted the importance of a positive attitude towards this period, the changes, challenges and insecurity occurring during menopause, which indicates a positive attitude towards health and coping with menopausal symptoms.
More than half of the participants agreed that physical activity attenuates many of the adverse health effects that frequently accompany the menopausal transition.It may help prevent several chronic diseases.More than half of the participants engage in regular physical activity at least once or twice a week and one third of the participants exercise three times or more per week.Surprisingly, two thirds of the EU's population are not enough physically active despite the well-documented benefits of regular physical activity (Drev, 2010).According to the Spanish research (Villaverde-Gutierrez, et al., 2006), habitual participation in physical activity results in many health benefits and statistically significantly improves menopausal symptoms and the health-related quality of life in the postmenopausal period.Similar results were obtained in the literature review study conducted by Marn Radoš and Šćepanović (2014).
The assessment of the respondents' lifestyle included also factors over which patients have some control, including bad habits.One third of the respondents are smokers, which corresponds to the average smoking rate in the EU member states (Koprivnikar, 2010).The extensive research conducted in Denmark (Pisinger, et al., 2009) confirms the relationship between healthy lifestyle and self-reported health in a general population.
There were several requests for more information on menopause despite high educational level of the participants.This finding has an important implication for nurses in the referential family outpatient clinics who could provide also counselling to menopause women.Foreign research (Sveinsdóttir & Ólafsson, 2006) established that action needs to be taken in order to strengthen the advisory role of nurses.The internationally well accepted standardised questionnaire MRS is recommended to measure the severity of menopausal symptoms in the referential family out-patient clinic, which proved useful also in the present study.
A limitation of the study was a relatively small sample size.For this reason, these results need to be interpreted with caution as they might not be transferable or generalized to a broader community.Further, more extensive targeted research on menopause and access to information needs therefore be undertaken on a larger sample of population.The present sample includes women with high average educational level, which should be taken into consideration in sampling of future research and comparison of results.
Further quantitative and qualitative studies with interviews are recommended to gain a better understanding and insight into the research problem.This recommendation is based also on the fact that a number of participants expressed a wish for further discussion of the issue.

Conclusion
There are some important issues emerging from this study.Most of the respondents rate their health as good or very good, they have a positive attitude towards health and live a healthy lifestyle.They are also aware of what they should do or avoid in terms of lifestyle and diet to improve their quality of life.They did, however, express the need for more information, especially from healthcare providers.At the end of the survey, a number of participants visited or called the interviewers and expressed a need for additional information on menopause which could be provided through lectures or workshops.It is important that health professionals offer women the information about all the symptoms, complications and some ways of controlling menopausal symptoms.Preparedness, positive attitude and knowledge help women embrace the physical, psychological and emotional changes occurring in menopause.Therefore, the authors suggest that the nurse in the family out-patient clinic introduces individual counselling on menopause or organises lectures or workshops for the targeted population of women aged 45-55 years.They also recommend the use of MRS questionnaire to measure the severity of symptoms.Additional education for nurses should be accordingly provided to empower nurses with the relevant knowledge.Additional tasks will require also additional workforce.

Table 1 :
Comparison of groups of women in perimenopause and menopause regarding the severity of menopause symptoms Tabela 1: Primerjava skupine žensk v perimenopavzi s skupino žensk v menopavzi glede na jakost menopavzalnih simptomov

Table 2 :
Searching for information related to health and menopauseTabela 2: Iskanje informacij v zvezi z zdravjem in menopavzo

Table 3 :
Presentation of the codes and subcategories with some statements Tabela 3: Prikaz kod in podkategorij z izjavami 'It is important to talk about the issue in question with people whom we trust.' '/…/ it is important to discuss these things.''… I have a friend.We discussed this issue a lot and she was the one who helped me most in coping with this transition.''A good partner relationship was of crucial importance...' Legend/Legenda: f − frequency/frekvenca; % − percentage/odstotek

Table 1 :
Comparison of groups of women in perimenopause and menopause regarding the severity of menopause symptoms

Table 2 :
Searching for information related to health and menopause

Table 3 :
Presentation of the codes and subcategories with some statements