Muturitus, 3 (1981) 11-20 0 Elsevier/North-Holland Biomedical Press

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CLIMACTERIC SYMPTOMS: A STUDY IN THE INDIAN CONTEXT

VINOD KUMAR SHARMA and M.S.L. SAXENA

Department of Psychology, Banaras Hindu University, Varanasi-221005, India

(Received 25 March 1980; accepted after revision 13 October 1980)

The climacteric is a universal phenomenon which has received relatively little attention from psychiatrists, psychologists, sociologists, anthropologists and social workers all over the world, but almost no research on this subje;c h.as been carried out in the third-world countries. This study, carried out in India, has been conducted for the purpose of unravelling the difficulties that Indian women have to face during the climacteric.

405 married women between 40 and 55 yr of age from the general population were contacted and interviewed.

The results, obtained with the menopausal symptom checklist prepared by the authors, indicate (as do other recent surveys) that hot flushes, night sweats and insomnia seem to be clearly associated with the menopause. Also the incidence of other symptoms is described. Despite embarrassment or dis- comfort experienced from these symptoms by a majority of women, only 10% had apparently sought medical treatment. This study underlines the necessity of a multidisciplinary approach to the problems of menopause and ageing.

(Key words: Menopause, Menstrual age groups, Indian women; Climacteric symptoms)

INTRODUCTION

According to the Demographic Year Book of the United Nations [3] there were almost 302 million women out of a total population of 626 million in India in 1977. Of these 302 million women 15 million were between 40 and 45, 12 million were between 45 and 50, almost 10 million between 50 and 55 and almost 8 million were between 55 and 60 yr of age.

The number of women over 40 is rapidly increasing, both in absolute and relative figures. This increase in numbers of this age group constitutes in itself a valid reason for the growing interest in the medical and social problems of the ageing woman.

Fortunately, as a subject for scientific study the menopause has gained increasing recognition, particularly in the last three decades. Extensive surveys to outline the symp- toms characterizing the climacteric phase were undertaken by a number of investigators [4,10,14,18,19,21,24,26,27]. Other investigators attempted to delineate the age at which menopause occurs 111 ,I 2,15,18,19,22,26,29], while others extended their research to

Address for correspondence: Vinod Kumar Sharma, c/o Mr. P.C. Sharma, 7/7 Kalkaji Extension, New Delhi - 110019, India.

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find out what environmental variables affect this age [1,7]. Apart from the climacteric symptoms and the age at menopause, measurement of attitudes towards the menopause is another important variable that has been widely explored [9,13,20].

In spite of this upsurge of research on various aspects of the menopause, the third- world countries, particularly India, have remained free of its impact. Flint [6] very rightly observed that almost no research has been done on this problem in third-world countries. Barring a survey conducted by Flint [5] on 483 Indian women of the Rajput caste in the states of Himachal Pradesh and Rajasthan and the one by Wyon et al. [29] to assess the differential age at menopause in the rural Punjab, we have yet to come across a survey that has been aimed at discovering the extent to which the so-called “climacteric syndrome” troubles Indian women.

THE CASE OF AN AVERAGE INDIAN WOMAN

Crawford [2] emphasized that the climacteric is a climactic event in a woman’s life. This also holds true for the average Indian woman. She experiences the menopause at a time when significant changes are also taking place within the family. Her children. are growing up and leaving home (particularly daughters who get married) all within a range of 5 yr around her 50th birthday. In addition to this it may also be a time when her hus- band is facing the last chance of promotion before retirement or he may be due for retire- ment. Thus she has additional problems to cope with. This observation is in consonance with Van Keep’s [27] finding that the woman for whom the menopause will be most difficult is a typical housewife, with a “limited intelligence”, and no or hardly any inter- est outside her own limited circle. The Indian woman, likewise, has to put everything into her traditional roles of wife and mother. This means that she has to stay home raising a family, putting all her energy into serving her husband and her family, and being identi- fied through them. Her household and her family are her pride. It is no wonder then that for these women the menopause suddenly signals a time when nothing is left of the life into which they invested almost everything they thought to have.

Adding further stress to this is the fact that menopause is a taboo subject for Indian women, and as such it is somewhat mystical and surrounded by misinformation. Because of this, and because of their stoic attitudes, Indian women tend to ignore the menopause and its related problems to an even greater degree than other health issues.

This study is presumably one of the first to investigate how the menopause is experienced by Indian women, in general. Apart from the attention paid to climacteric symptoms, an attempt has been made to explore some changes of a more general nature associated with the menstrual cycle at this time of life.

SAMPLE AND METHODS

The population studied

This survey was carried out in the second half of 1978 in Varanasi City, India, of which the total female population was about 270000 and relevant [28]. 405 married women, 40 to 55 yr of age and living with their husbands, were interviewed with a symp-

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tom checklist prepared by the authors. These women, who had at least one of their children living with them, were contacted either through personal contacts, women clubs or public schools. Subjects with a history of major physical illness, disability or artificial menopause were omitted from the sample.

India is a country of wide ethnicity and in a survey like this, one is bound to come into contact with many caste groups. For this survey we made no conscious effort to select a fixed number of women from a particular caste, and accordingly, women were drawn from all castes such as Brahmins, Rajputs, Kshatriyas, Kayasthas, Sikhs, Muslims, Christians and Harijans, Although women from no socio-economic status groups were excluded from the sample, the majority of women came from upper-middle and lower- middle socio-economic groups. All women who participated had an educational level of at least Junior High School.

Because of the personal nature of the questions, the interviews were conducted in the homes of the respondents by the senior author’s wife who was specially trained in the technique. It is very difficult, if not impossible, for a male investigator to collect data from Indian women on such a sensitive issue. Therefore, at the very outset, the survey was planned in a manner in which a female investigator could be employed.

MENOPAUSALSTATUS

According to the literature vasomotor symptoms may occur before, during or for some years after the cessation of menses. Keeping this in mind, Neugarten and Kraines [21] employed self-evaluation criteria to determine the menopausal status of the respondents. In addition most other investigators relied on a subjective evaluation of menstrual irregularities as adequate indicators to differentiate the peri-menopausal from the pre- or post-menopausal phases.

In this study the division according to Jaszmann et al. [lo] has been used. (a) Pre- menopausal: women who had normal menses during the year preceding the survey; (b) per&menopausal: women reporting a menstrual pattern different from the former pattern; (c) post-menopausal: women who did not menstruate in the year preceding the survey.

ASSESSMENTOFCLIMACTERICSYMPTOMS

A symptom checklist was prepared mainly based on Neugarten and Kraines’ [21] menopausal symptom checklist, to which a few symptoms, typical for the Indian situa- tion, were added.

The questionnaire used had three sections; A, B and C. Section A deals with hot flushes (their current status, intensity, duration and location on the body), night sweats (their current status, intensity and duration) and sleeplessness’(its current status, duration and accompanying symptoms). Section B consists of 30 other symptoms (somatic, psychosomatic and psychological) which are marked on a four-point scale labelled “always, often; occasionally and never”. Section C consists of three statements related to menstrual history. It is this section which helped in determining the menopausal status.

The items in the questionnaire were worded in simple Hindi and the subjects were repeatedly advised that they had to report the extent to which they were bothered by

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each of the symptoms during the year preceding the survey. Of the 33 climacteric symp toms, 11 were somatic, 5 psychosomatic and the remaining 17 were psychic symptoms.

A number of ways to analyse statistically the answers to the symptom checklist were employed. Since the scoring system is outside the scope of the present paper, it has been discussed elsewhere [27].

RESULTS

Section A

Hotjlushes Table I shows the relative incidence of hot flushes. The fact that about the same percentage of women in three analysis groups currently

experiences hot flushes leads us to the conclusion that these are experienced by most women over quite a period of time. However, in regard to site/location, frequency/inten- sity and duration some clear differences do emerge.

Of those who had experienced hot flushes and who were still menstruating regularly, 8% reported experiencing them around the face and neck, 39% reported them in different locations while 14% reported them to be over the whole body. Women whose menses had been irregular also reported hot flushes - 3% around the face or neck; 44% in different locations and 12% over the whole body. Women whose menses had ceased completely, however, reported a slightly different pattern - 7% around the face or neck; 29% in different locations and 35% over the whole body. Since the whole body sensation implies greater intensity, it would seem that women who are past their last menstrual period are likely to experience,the most intense flushing.

There is also evidence that hot flushes are experienced by most women over a period of years. 11% of the women with regular menstrual periods experienced hot flushes for less than 6 mth and an equal number of women experienced them from 6 to 12 mth, while 35% of the women experienced them for 1 yr or more. 13% of the women with irregular menses experienced hot flushes for less than 6 mth; l?% between 6 and 12 mth and 34% for more than a year. Among the women whose menses had ceased, 44%

TABLE I

The percentage of women in the various menstrual age groups who are currently experiencing hot flushes, who did so in the past and who never experienced these.

Number Hot flushes

Currently experiencing (%I

Stopped (%I

Never experienced (%I

Pre-menopausal 135 59 4 36 Peri-menopausal 135 61 4 36 Post-menopausal 135 61 8 30 Total 405

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reported experiencing them for more than a year, 15% reported experiencing them for less than a year, while only 6% reported experiencing them for less than 6 mth.

23% of the pre-menopausal women reported flushing at its greatest intensity at least once a day, 30% weekly or less and 7% every few hours. For 14% of the women with irregular menstrual pattern, flushing occurred every few hours, for 25% at least once a day and for the same percentage weekly or less. For 11% of the post-menopausal women, flushing occurred every few hours, for 25% at least once a day and for the same percent- age weekly or less. For 11% of the post-menopausal women, flushing occurred every few hours, for 27% at least once a day and for 3 1% weekly or less.

Our results are comparable with the results reported by Jaszmann et al. [lo], Prill [23], Mckinlay and Jefferys [16] and Thompson et al. [26].

Night sweats Night sweats are also a disturbing symptom experienced by 41% of the currently

menstruating (pre-menopausal) women, 53% of women with an irregular menstrual pat- tern and 58% of women whose menstrual cycles have ceased.

Like hot flushes, night sweats tend to become more severe with increasing biological age. They are reported to be “severe” by 17% of the pre-menopausal, 27% of the peri- menopausal and 41% of the post-menopausal women.

It is noteworthy that a few women reported experiencing night sweats in the past year without also reporting hot flushes.

Sleeplessness 54% of the women who have regular menses complain of insomnia to varying degrees,

whereas the percentage is 67% in the case of per&menopausal women. 64% of the post- menopausal women suffer from this complaint.

Like hot flushes and night sweats, insomnia is also experienced over a period of years. Pre-, peri-, and post-menopausal women state in 25%, 40% and 47%, respectively, to have suffered from this complaint longer than 1 yr.

Insomnia may be accompanied by other symptoms. 16% of pre-menopausal women, 27% of peri-menopausal women and 34% of post-menopausal women reported hot or cold sweats along with sleeplessness. ANS sensations of falling along with sleeplessness are reported frequently by all three menopausal age-groups, 44%, 50% and 49%, respectively. Nightmares accompanying insomnia are mentioned in 1 l%, 14% and 14%, respectively.

Section B

Table II shows the incidence (in percentages) of each symptom on the checklist for each of the three menstrual age groups.

There are clear differences between the peri-menopausal women and women of the other two groups on a number of symptoms on the checklist. This is to say that the peri- menopausal group leads the other two groups in the reporting of these symptoms. 3 symptoms (nervousness, awareness of onset of old age and depression) do not differenti- ate with menopausal status. On the other hand, there are differences between post-meno- pausal women and women of the other two groups on about 11 symptoms on the check-

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TABLE II

The percentage of women currently reporting symptoms in each menstrual age group.

Symptoms/complaints Menopausal status

Pre- menopausal

Peri- menopausal

Post- menopausal

Somatic Hot flushes Night sweats Diarrhoea Constipation Backaches Breast Pains Cold hands and feet Numbness/tingling Swollen ankles and feet Rheumatic pains Weight change Psychosomatic Palpitations/pounding heart Dizziness/dizzy spells Feelings of tiredness Black spots before the eyes Headaches Psychological Sleeplessness Crying spells Tension Nervousness Lack of concentration Feeling blue Irritability Forgetfulness Feelings of fright/dread Worry about going crazy Feelings of suffocation Mood fluctuations Hypochondriacal feelings Awareness of the onset of old age Restlessness/excitement Depression Guilt proneness (feelings)

59 61 61 41 53 58 41 45 50 51 51 55 62 71 64 31 42 43 33 34 36 66 69 64 71 56 59 17 17 21 55 70 56

67 75 64 65 74 67 89 93 88 60 69 66 76 86 82

54 67 64 51 54 63 56 64 63 68 68 67 63 67 69 56 68 67 65 67 59 47 49 52 50 49 49 55 50 51 44 44 47 66 77 66 41 46 41 70 80 80 67 70 61 59 68 68 39 46 36

list. On 3 symptoms on the checklist (swollen ankles and joints, feelings of fright, and worry about going crazy) there are differences between pre-menopausal women and the other two groups. The overall conclusion that the above analysis leads us to is that peri- menopausal women suffer most markedly from symptoms claimed to be associated directly or indirectly with menopause.

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Section C

The prevalence of problems associated with the menstrual cycle before and during menopause, has also been assessed by asking the women whether they experienced any specific problems during their periodic menstrual flow. (Post-menopausal women were asked to recollect if they had experienced such difficulties.) 59% of the pre-menopausal women reported “no difficulties at all” against only 40% of the pre-menopausal women. The main complaint in both groups were body aches and pains. The recollected com- plaints of the oldest group did not reveal anything worth reporting.

DISCUSSION

The findings reported in this paper pertain to “normal” women from Varanasi and it is not known whether and in how far these findings may be applicable to middle-aged women in India in general. A number of authors [7,14,21] have stated that when one explains the problems associated with menopause from the perspective of an interaction between biology and culture, one has to bear in mind that changes in culture will have consequences in the way in which women will experience the menopause. India is a country, rather a sub-continent, of wide ethnicity. Here we not only have a number of caste or religious groups but also a number of states. Each of these units, besides being geographically and climatically different, has its own cultural leanings, its own mores and taboos and its own values. That is, there is heterogeneity of thought, action and plan. It is this heterogeneity of religion, caste and culture which prevents us from generalising our findings to all Indian women. It is only when we have sufficient data from different caste and regional groups of middle-aged women from this country that we can attempt to generalise the findings.

As pointed out earlier, the purpose of the study was to gauge the incidence and sever- ity of climacteric symptoms among a sample of middle-aged women rather than to assuage the interaction between culture and symptom formation. The characteristics of the specific population, therefore, are not of great importance.

Apart from this limitation that stems from ethnic diversity, there are some other fac- tors that seem to operate in the inquiry. The foremost of these is the method of inquiry. The data were collected by means of personal interviews. This was necessitated by the fact that most middle-aged women in India are ill-informed about the menopause and are too shy and hesitant to consult a general practitioner or a gynaecologist. For this reason the survey was planned so that first a rapport with the woman was established and then, after gaining her confidence, an inquiry into “the private aspects of her life” was embarked upon. Thus, we have subscribed to Neugarten and Kraines’ approach [21] which stated that a written form of enquiry would be liable to a tendency of receiving more complaints than would have been gathered by a personal interview. The method of data collection used in this study ensures a reliable reporting of the true incidence of symptoms.

Jaszmann et al. [lo] contended that if climacteric symptoms are analysed on the basis of “menstrual age” then they should rarely be mentioned by pre-menopausal women, relatively frequently by peri-menopausal women and less often again by women who are

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post-menopausal. Our results tend to support this assumption, though with a differentia- tion. Symptoms have been reported quite heavily by all three analysis-groups though the peri-menopausal group surpassed the other two groups in 19 of the 33 symptoms listed on the checklist. On 11 of these symptoms, the post-menopausal group surpassed the other two, while the pre-menopausal group surpassed the peri-menopausal and post-meno- pausal groups in only 3 symptoms.

“Psychosomatic” symptoms seem to trouble the women most. On all 5 psychosomatic symptoms the per&menopausal group surpassed the other two groups in frequency. This is again consistent with Jaszmann et al.‘s [lo] findings. From a cultural perspective, this is also easy to explain regarding Indian women. All day she is busy with her household, looking after the home, cooking meals, washing clothes and rearing children. Fatigue and over-exertion are part of her life. It is not even surprising that she ages faster than western women and experiencies psychosomatic symptoms more than other symptoms (somatic and psychic).

CONCLUSIONS

The Indian women of the society under study seem to experience the climacteric phase as being more distressful than the western women. A number of reasons could well be given for this. Firstly, for the Indian woman the stoic attitude of the previous generation towards health issues is thought to be important in deciding whether or not to seek medical advice. This is primarily because these women are highly ignorant and ill-informed about the menopause and they are too embarrassed to discuss such issues with their hus- bands or elderly ladies of the house who have already experienced it. (There still are very many extended families in India. Even where the families are nuclear, at least three generations of people can commonly be found in a single family. It is always the senior- most generation of a family that dominates and does the decision-making. Hence genera- tionold values, attitudes, and customs operate in a family.)

The medical profession as well as the social scientists in India seem to be indifferent to the problems of middle-age in general, and of the menopause in particular.

The menopause has been reported to occur at an early age in India (44 yr) as com- pared to other countries [29]. It may be that an early menopause brings with it addi- tional difficulties. If so, it may explain why climacteric stress seems to be so prevalent with Indian women.

This situation, of course, poses a challenge to existing health services and some voluntary organisations like counselling services, and women’s organisations.

Considering the growing number of women over 40, the situation in India may require self-help clinics, menopausal rap-groups and other organisations that could educate the women who are relatively ignorant or ill informed about their bodies and about health issues. Through lectures, discussions, symposia, counselling and the like, these women could gain better insight into the difficulties associated with middle age in general, and the menopause and the climacteric in particular. This in turn would help millions of women to experience fewer problems with menopause. Education concerning the overall effects of ageing and the incidence of various symptoms, both favourable and unfavour- able, would also place the menopause in a better perspective.

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ACKNOWLEDGEMENTS

The authors express their gratitude to P.A. van Keep (Brussels), Bernice Neugarten (Chicago) and Marcha Flint (New Jersey) for their advice and encouragement, and for making available some highly relevant literature. Further, the authors are thankful to Mrs. Shashi Sharma, Miss Shashi Kiran and Mrs. Rani Saxena for putting in long hours in conducting interviews on middle-aged women at the cost of their domestic commitments.

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