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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 292-301

Effect of menopausal symptoms on psychological problems among middle-aged women


1 Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, Zagazig University, Zagazig, Egypt
2 Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Zagazig University, Zagazig, Egypt

Date of Submission16-Sep-2018
Date of Acceptance16-Oct-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Shadia Fathy Mahmoud Mohammed
Psychiatric and Mental Health Nursing, Faculty of Nursing, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_20_18

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  Abstract 


Background Menopause characterizes the end of the female reproductive period. Psychological problems such as anxiety and depression are reported among women in the menopausal period.
Aim The aim was to find out the effect of menopausal symptoms on psychological problems such as anxiety and depression among middle-aged women.
Participants and methods A descriptive cross-sectional design was used. This study was conducted at eight colleges from Zagazig University. A convenience sample composed of 200 menopausal women was recruited. Four tools were used for collection of data: interview questionnaire, menopause rating scale, Beck depression inventory scale, and Taylor manifest anxiety scale.
Results More than three-quarters of the studied women were aged 50 years and older, with the mean age being 53.6±6.3 years. Nearly half of them had severe menopausal symptoms. More than one-third had mild depression and more than half of them had severe anxiety.
Conclusion Nearly half of the studied women had severe menopausal symptoms. More than one-third had mild depression and more than half of them had severe anxiety. There were positive statistically significant correlations among total menopausal symptom, anxiety, and depression scores. Moreover, there were statistically significant relations between total menopausal symptom score and both educational level and duration of menopause.
Recommendations The present study emphasizes that depression and anxiety are commonly prevalent among the middle-aged women; therefore, women should be screened in the menopause transition period, especially for clinically significant depression and anxiety, as some changes in women lifestyle like diet and exercises can improve good mood. Moreover, training programs should be designed for middle-aged women to decrease psychological problems associated with menopause, and delivery of mental health services in this group is essential.

Keywords: anxiety, depression, menopause, middle-aged women


How to cite this article:
Mahmoud Mohammed SF, Mohammed NS. Effect of menopausal symptoms on psychological problems among middle-aged women. Egypt Nurs J 2018;15:292-301

How to cite this URL:
Mahmoud Mohammed SF, Mohammed NS. Effect of menopausal symptoms on psychological problems among middle-aged women. Egypt Nurs J [serial online] 2018 [cited 2019 Aug 17];15:292-301. Available from: http://www.enj.eg.net/text.asp?2018/15/3/292/248963




  Introduction Top


Menopause characterizes the end of the female reproductive period. During the menopausal transition period, there is a progressive and irreversible decline of ovarian function, which causes an array of symptoms (Nuńez-Pizarro et al., 2017). Alterations in menstrual bleeding manner indicate the near of menopause in mid-life women, and several women describe hot flashes, inadequate sleep, depressed mood, anxiety, and additional symptoms along with these menstrual variations (Llaneza et al., 2012).Menopause is connected with ceasing of ovulation, and it usually happens in 47–53 year olds. Estrogen deficiency causes hot flashes, sleep disturbance, atrophy, vaginal dryness, and cognitive-emotional disorders. Osteoporosis, dementia, and cardiovascular disease risks are consequently elevated in postmenopausal women. The depression throughout the menopause is related to empty nest syndrome (Charmchi and Khalatbari, 2011; Gümüsay and Erbil, 2016).

Depressive symptoms are frequent in all populations but seem to rise among women in the transition to menopause. Major depression is more common in women than in men in all age groups till later life, with a lifetime prevalence of 21% compared with 12% for men in the National Comorbidity Survey (Freeman, 2015). Depression in women also seems to increase around reproductive events. Postpartum depression following childbirth, premenstrual dysphoric disorder connected to the menstrual cycle, and depression nearby menopause may possibly share sensitivity to normal changes in reproductive hormones, which in turn modify neuroregulatory systems linked with mood and behavior (Schmidt and Rubinow, 2009).

Psychological problems, especially depression, are one of the main problems influencing postmenopausal women in several communities. The prevalence of depression, the most recurrent mood disturbance (sometimes labeled psychological flu), is reportedly 43% during menopause (Dolatian et al., 2006). Depression is a frequent and chief complaint among some mid-life women. It adversely influences an individual’s social relationship and the ability to work and learn and is a marker of the risk of self-harm and suicide (Zang et al., 2016).

Anxiety is highly prevalent during the peri- and early postmenopausal stage, mainly owing to hormonal changes (Bromberger et al., 2013). Anxiety is observed in 5–15% of the population and is two to three times more likely to influence women. A study conducted by Sagzoz and colleagues utilizing the Beck depression inventory (BDI) displayed that depression and anxiety can be elevated in postmenopausal women (Rasooli et al., 2004).

Significance of the study

The WHO that depression and anxiety threaten to be the world’s greatest common illness by the end of the century, particularly in middle-aged women WHO Reports (2002). In Egypt, the mean age of the menopause is 46.7 years, which is low compared with several countries, but this age has been increasing recently. The incidence of menopause-related symptoms in Egyptian women is higher than in the West, perhaps owing to the diverse ‘sociocultural attitudes’ regarding the menopause. In our health system, in Middle East countries, women of the reproductive age group are taking more significance. Menopausal women in both the urban and the rural areas are ignored (Sallam et al., 2006). In addition, menopausal women described more psychological stress, more medical troubles, and lower self-esteem than men. Anxiety and depressive disorders are among the utmost common psychiatric disorders in the community. Conversely, most women with these disorders go undetected (Obadeji et al., 2015).

Therefore, this study is significant, as it finds out the effect of menopausal symptoms on psychological problems such as anxiety and depression among the middle-age women. The present study findings can be helpful for menopausal women by providing information about health problems of middle age in women as a part of an important strategy to prevent these problems among women permenopausal age, especially in developing countries such as Egypt. As a greater number of women in middle age experience health problems related to menopause, it hinders their ability to develop to their full potential. Moreover, it might produce attention and incentive for future research into this area.


  Aim Top


This study was aimed to find out the effect of menopausal symptoms on psychological problems such as anxiety and depression among middle-age women.

Research question

What is the effect of menopausal symptoms on psychological problems among middle-age women?


  Participants and methods Top


Research design

A descriptive cross-sectional design was used in the current study to assess the sociodemographics and anthropometric profile and correlate them with the severity of menopausal symptoms and degree of anxiety and depression in postmenopausal women.

Setting of the study

This study was conducted at eight colleges selected randomly from Zagazig University (Nursing, Education, Commerce, Literature, Engineering, Pharmacy, Medicine, and Faculty of Science).

Participants

A convenience sample of 200 women, all available women, who were working as administrators and workers at the selected eight colleges in Zagazig University were recruited for the study.

Inclusion criteria

The following were the inclusion criteria:
  1. Women aged between 40 and 55 years or older.
  2. Women who have menopausal symptoms.
  3. Women who have stopped menstruation for at least 6–12 months.


Exclusion criteria

The following were the exclusion criteria:
  1. Women who have reached menopause surgically.
  2. Women who are using hormonal replacement therapy.
  3. Women who had been treated by chemotherapy.


Tools for data collection: four tools were used for data collection:

Tool I (interview questionnaire): the study questionnaire was designed by the researchers after revising of the related literature and getting opinions of experts for content and validity and included the following: sociodemographic characteristics, namely, age, marital status, educational level and BMI; moreover, the medical and obstetric history was evaluated.

Tool II [(menopause rating scale (MRS)]: the MRS comprised of 11 elements assessing menopausal symptoms. Each element can be classified from 0 to 4 (0=no symptoms to 4=most severe), which are separated into three subscales: somatic symptoms (e.g. sweating, heart problems, and joint/muscle aching), urogenital symptoms (e.g. sexual complications, urinary complications, and vaginal dryness), and psychological symptoms (e.g. depression, irritability, and anxiety). The total score is determined by summing up the scores for each dominion. Higher MRS scores are suggestive of more severe symptoms. A total MRS score of greater than or equal to 17 was defined as severe quality of life impairment. Heinemann et al. (2004) have proposed cutoff values to define severe symptoms according to each subscale: somatic (>8), psychological (>6), and urogenital (>3).

Tool III (Beck depression inventory scale): it was developed by Beck et al. (1996) and is a self-report record and unique among the most greatly utilized scales for appraising the severity of depression. It was used to assess the level and intensity of depression, which consist of 21 self-report items that evaluate the presence and severity of depressive symptoms over the past 2 weeks such as hopelessness, suicidal ideation, and loss of interest. Statements are measured on a four-point Likert scale extending from 0 to 3. Scores are categorized as follows: 0–13 minimal range, 14–19 mild, 20–28 moderate, and 29–63 severe range of depression.

Tool IV (Taylor manifest anxiety scale): it was developed by Taylor (1953) and is used to assess anxiety. It has a high degree of validity and reliability. The scale has 50 statements with Yes/No answer. The number of ‘Yes’ responses is calculated by simple summation. The scores are categorized by levels of anxiety as follows: non: less than 17, mild: 17–20, moderate: 21–26, severe: 27–29, and very severe: 30+.

Ethical considerations

To carry out the study, the necessary official approval was obtained from the manager of the selected eight colleges. The aim of the study was explained to each woman, and an oral consent to participate was obtained. Women were assured that the obtained information will be treated confidentially and will be used only for the purpose of the study.

Procedure of data collection

  1. Validity of the research tools was ensured through a review by 3 experts who hold a DNSc in nursing, and the necessary modifications were made. The language of the tools was also tested for clarity of meaning.
  2. The agreement was obtained from women verbally before being involved in the study to them. During the meeting, the questionnaire was filled in to assess the severity of menopausal symptoms; moreover, anxiety and depression scales were also filled in.
  3. An official permission was taken from the director of the selected eight colleges in Zagazig University.
  4. A pilot study was conducted on 10% of the study participants to ensure the possibility of the tools and estimate time needed to answer the questions.
  5. Data collection for the study was carried out over a time of 4 months from beginning of June 2016 to end of September 2016.
  6. The researchers informed the women that sharing information is voluntary, and privacy of information will be ensured and that they have the right to withdraw at any time without giving any reason.
  7. Researchers interviewed the women face to face. They presented themselves to the suitable women and concisely clarified the nature of the study.
  8. The filling of the questionnaire took 30–45 min by participants.
  9. The researchers spent 3–3 days every week, and on each day, they interviewed about five women maximally.


Statistical analysis

All data were coded, organized, and subjected to statistical analysis, which was performed utilizing the statistical package for the social sciences (SPSS; SPSS Inc., Chicago, Illinois, USA) version 20. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and means and SDs for quantitative variables. Percentages of categorical data were compared by χ2-test. Spearman’s rank correlation coefficient was calculated to assess the relationship between the various study variables. P value less than 0.05 was considered significant (S).


  Results Top


[Table 1] displays the sociodemographic characteristics of the studied sample. More than three-quarters of the studied sample (77%) were aged 50 years and older, with a mean±SD of 53.6±6.3, having an age range between 40 and 65 years. Among them, 72% were married and 45% had secondary education. This table also shows that in more than two-thirds of the studied sample (68%), the duration of menopause ranged from 1–6 years. Slightly more than half of them (52%) were nonobese, and 68% had health problems. More than three-quarters (78%) were nonsmokers. Most of them (95%) had previous pregnancy and 83.2% had normal labor.
Table 1 Sociodemographic characteristics of the studied sample (n=200)

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[Table 2] indicates that nearly half of the studied sample (49%) had severe menopausal symptom. Among them, 68% had mild to moderate somatic symptoms, 54% had mild to moderate psychological symptoms, and more than half (58%) of the studied sample had severe urogenital symptoms.
Table 2 Frequency distribution of menopausal symptom subscales among the studied sample

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[Table 3] and [Figure 1] and [Figure 2] illustrate the frequency distribution of depression and anxiety levels among the studied sample. Slightly more than one-third (34%) of the studied sample had mild depression, whereas more than half of them (59%) had severe anxiety and 24% had moderate anxiety.
Table 3 Frequency distribution of depression and anxiety levels among the studied sample

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Figure 1 Percentage of depression grade among the studied sample.

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Figure 2 Percentage of anxiety grade among the studied sample.

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[Table 4] presents the relation between demographic characteristics and total menopausal symptom score among the studied sample. This table shows statistically significant relation between total menopausal symptom score and both educational level and duration of menopause among the studied sample (P<0.05).
Table 4 Relations between demographic characteristics and total menopausal symptoms score among the studied sample

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[Table 5] demonstrates statistically significant relations between anxiety grade and marital status, educational level, and health problems among the studied sample (P<0.05).
Table 5 Relations between demographic characteristics and anxiety grade among the studied sample

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[Table 6] shows statistically significant relations between depression grade and age group, educational level, duration of menopause in years, and health problems among the studied sample (P<0.05).
Table 6 Relations between demographic characteristics and depression grade among the studied sample

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[Table 7] and [Figure 3] and [Figure 4] demonstrate correlations between total menopausal symptom and the studied variables. This table shows positive statistically significant correlations among total menopausal symptom, anxiety, and depression scores (P<0.05).
Table 7 Correlations between total menopausal symptom and the studied variables

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Figure 3 Positive significant correlation between the total menopausal symptom and depression score.

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Figure 4 Positive significant correlation between total menopausal symptom with anxiety score.

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  Discussion Top


Women go through different stages of life cycle, and each stage of life is affected by certain aspects such as infancy, childhood, adolescent, adult, middle age, and old age. Menopause has been assumed to be a main transition point in women’s reproductive and emotional life. Physiological changes of postmenopausal period are very important as they influence psychological, social, and emotional aspects of women life. Psychological problems affect physical well-being, causing chronic fatigue, sleep disturbance, and disturbance of appetite. They influence mood, with feelings of sadness, emptiness, hopelessness, and dysphoria, which disturb concentration and decision making. It is believed that a cause of depression and anxiety results from an alteration in estrogen levels, which occur during menopause (Lampio et al., 2014).

The current study results showed that more than three-quarters of the study participants were in the age group 50 years with mean±SD of 53.6±6.3 years, less than three-quarters were married, and more than two-thirds had menopause from 1–5 years. Moreover, nearly half of them had secondary education. This was in agreement and explained in previous findings by Sallam et al. (2006), who reported that the mean age of menopause in Egypt is 46.7 years, which is low compared with several countries, but this age has been increasing recently. The incidence of menopause-related symptoms in Egyptian women is higher than in the West, perhaps owing to the diverse ‘sociocultural attitudes’ regarding the menopause in various communities. However, Potdar and Shinde (2014) who studied ‘Psychological Problems and Coping Strategies Adopted by Post-Menopausal in Indian Women’ was in disagreement with the previous finding and indicated that 47.7 years was the mean age of menopause, 67% of the women were illiterate, 82% were unemployed/housewife, 64% were married, and 36% had attained menopause 10–12 years ago.

Regarding the presence of health problems, the results of the present study found that more than two-thirds of the study sample had health problems. Moreover, most of them had previous pregnancy and the majority had normal vaginal delivery. From the researchers’ point of view, most of menopausal women perceive menopause as natural condition and did not connect this health problem with hormonal disturbance of menopause. This result is in contrast with Potdar and Shinde (2014), who reported that 92% had no diseases before menopause, and 85% had no diseases after menopause.

Investigating the severity of the menopausal symptoms among the study participants, the present study results reported that nearly half of them had severe total menopausal symptoms. More than two-thirds had mild to moderate somatic symptoms, whereas more than half of them had psychological symptoms and severe urogenital symptoms. This may be explained by that majority of menopausal women were not aware about hormone replacement therapy that can alleviate severity of menopausal symptoms. Yakout et al. (2011) in their study about ‘Menopausal symptoms and quality of life among Saudi women in Riyadh and Taif’ found that, the uppermost mean scores of menopausal symptoms were in diverse domains of urinary tract, muscles and skeletal paralleled to cardiovascular which are the lowermost. Similarly, Moustafa et al. (2015) stated that more than one-third of women have severe urinary bladder problems in their study ‘Impact of menopausal symptoms on quality of life among women in Qena City’.

Concerning depression and anxiety levels among the studied sample, the present study results found that, more than one-third of the studied sample had mild depression whereas more than half of them had severe anxiety level, and ∼one-quarter had moderate anxiety. This may be due to at menopausal stage, women use different strategies to alleviate menopausal symptoms and depression like praying, exercise and nutrition. In the same line, Bansal et al. (2015) in their study about depression and anxiety in rural Punjab reported that the levels of depression and anxiety represented 86.7 and 88.9%, respectively. Most of the participants had moderate type of depression (49.5%) followed by mild (29.4%) and severe depression (7.8%). However, in the case of anxiety, less than three-quarters of the participants (69.4%) had a mild form of anxiety and 17.8% had moderate anxiety level.

Moreover, Jennifer et al. (2013) cited that less than half of the women had at least one of the enumerated symptoms such as anxiety, depression, hot flushes, sleep disturbance, and vaginal dryness in their study ‘The impact of menopausal symptoms on quality of life, productivity and economic outcomes’. In contrast, Moustafa et al. (2015) reported that less than half of their study sample had severe depressed mood in their study ‘Impact of menopausal symptoms on quality of life among women in Qena City’.

According to the current study results, there were statistically significant relations between total menopausal symptoms score and both educational level and duration of menopause among the studied sample. These results were to some extent supported by Bener et al. (2017), who studied ‘depression, anxiety, and stress symptoms in menopausal Arab women’ and reported that there were statistically significant differences between menopausal stages regarding age, ethnicity, educational levels, occupation status, and place of living.

Regarding the relations between anxiety and demographic characteristics, the current study results demonstrate statistically significant relations between anxiety grade and marital status, educational level, and health problems among the studied sample (P<0.05). In the same line, Bener et al. (2017) who studied depression, anxiety, and stress symptoms in menopausal Arab women reported that there were statistically significant differences between menopausal stages with regards to age, ethnicity, educational levels, occupation status, and place of living. Moreover, these results are consistent with those of Bansal et al. (2015), who in their study ‘Depression and anxiety in rural Punjab’ found a significant relationship between anxiety levels and marital state. Moderate anxiety was found more common among widows (44.4%) as compared with presently married women (14.8%).

Considering the relations between demographic characteristics and depression grade among the studied sample, there were statistically significant relations between depression grade and age group, educational level, duration of menopause in year, and health problems among the studied sample. These findings were in contrast with those of Bansal et al. (2015), who reported that with increasing age, there was an increasing trend for depression; however, this difference was found to be statistically non-significant (P=0.101). Depression was not found to be significantly affected by education, BMI, and socioeconomic status.

The present study results showed positive significant correlations between total menopausal symptom with anxiety and depression scores. These findings were in agreement with several studies such as those of Chedraui et al. (2009), Reed et al. (2009), and Freeman (2010), who examined the relationship between severity of menopausal symptoms with depression, anxiety, and other menopausal symptoms in Iran and found similar results. Similarly, Ziagham et al. (2015) in their study ‘The relationship between menopausal symptoms, menopausal age and body mass index with depression in menopausal women of Ahvaz in 2012’ reported a statistically significant relationship between depression and menopausal symptoms in all the three areas. However, conflicting results were noticed in the study of Bahrim et al. (2013), which found no significant relationship between the severity of menopausal symptoms and the two variables of depression and anxiety. Moreover, Bener et al. (2017) reported that there is a strong association between depression, anxiety, and stress symptoms, with high rates in menopause and postmenopausal women.


  Conclusion Top


The study concluded that more than three-quarters of the studied sample were aged fifty years and older. Nearly half of them had severe menopausal symptom. More than one-third had mild depression and more than half of them had severe anxiety. There were positive statistically significant correlations between total menopausal symptom, anxiety and depression scores, and also, there were statistically significant relation between total menopausal symptom score and both educational level and duration of menopause.

Recommendations

Depending on the current study results, the following recommendations were advised:
  1. Women should be enlightened, screened, and prepared for possible physical and psychological problems of menopause especially for clinically significant depression and anxiety, and staying connected with the family and friends can nurture well-being.
  2. Attention of changing lifestyle such as self-supporting skills such as yoga, rhythmic breathing and meditation are helpful in menopause. Moreover, healthy food and exercise can improve good mood.
  3. Training programs should be designed for middle-aged women to decrease psychological problems associated with menopausal symptoms.
[28]

Financial support and sponsorship

Nil.Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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