Factors Influencing the Natural Menopause Age among Women Attending Gynaecology Outpatient Clinic at a Tertiary Care Hospital in Central India

Introduction

Women's reproductive years come to an end with menopause, an important step in the continuum of life stages. A woman cannot conceive after menopause, with the possible exception of rare instances in which specialist fertility therapies are employed. Natural menopause, as defined by the World Health Organization, is the end of menstruation due to ovarian follicular activity decline without a clear cause and is verified by amenorrhea for 12 consecutive months. Menopause occurs naturally in most women between the ages of 45 and 55 years as a result of biological aging.^1,2 Because age at natural menopause (ANM) has multiple possible therapeutic consequences, menopause-related studies in recent decades require extensive research in the field of related factors. Women experiencing an early menopause are at high risk for cardiovascular disease, cardiovascular mortality, depression, osteoporosis, fractures and other diseases.³

Aims and objectives of the present study were -

1. To study socio demographic factors associated with the age of menopause

2. To study life style factors associated with the age of menopause

3. To study menstrual and reproductive factors associated with the age of menopause

Material and Methods

This was a cross-sectional study conducted among middle aged women between 45-65 years of age visiting Obstetrics and Gynaecology Department of Kamla Raja Hospital at Madhav Dispensary and Jaya Arogya Group of Hospitals in G.R. Medical College, Gwalior during the period 1st January 2017 to 30th June 2018.

Inclusion Criteria

Women in the age group of 45 to 65 years, having amenorrhea for at least past 12 months, consenting to participate in the study were included.

Exclusion Criteria

Pregnant and breast-feeding women, women with uncontrolled medical conditions such as hypertension, diabetes mellitus, heart disease, patients undergoing treatment for cancer, or those on remission, women on hormone replacement therapy, severely ill patients and those not willing to participate were excluded from the study.

Sample Size

The sample size was calculated by using formula 4PQ /L2, Where P (=25%) was proportion of menopausal women having age at natural menopause as 45 years (25 percentile) in Madhya Pradesh and Q was 100-P, L was (5% absolute error considered) allowable error and at 5% level of significance.⁴ Calculated sample size was 300, assuming 10% non-response rate.

Sampling Tool and Technique

The study procedure involved a face-to-face interview with the participants using a predesigned questionnaire in Hindi language. For the selection of cases, convenient sampling was adopted. The subjects who fulfilled the inclusion criteria were selected from the patients visiting the OPD of Obstetrics and Gynaecology department. For every four eligible subjects visiting the department, one participants was randomly selected for the present study.

Statistical Analysis

Data were entered into MS Excel 2007 and analysis was done. Frequency and percentages were calculated and the statistical analysis was done using Chi square test. P value <0.05 was considered to be statistically significant and P value >0.05 was considered non-significant. Logistic regression analysis was performed and odds ratio (OR) along with their 95% CI were calculated.

Ethical Consideration

Informed written consent was obtained from the participants and the anonymity was maintained. Ethical approval was taken from the ethical committee of G.R. Medical College, Gwalior for conducting the study (D.No. 320/Bio/MC/Ethical Dated 11/04/2017).

Results

The mean age of postmenopausal women was 52.71±5.27 years. The mean age at natural menopause was found to be 45.65±4.44 years. Out of the total 330 postmenopausal women, maximum number of participants (44.84%) were in 45-50 year age group, followed by 56-60 year age group (30.30%). Out of the total 330 postmenopausal women, 63.03% participants were from urban areas. Out of the total 330 postmenopausal women, maximum number of participants (70.51%) were Hindus, followed by Muslims (23.03%). Out of the total 330 postmenopausal women, 61.21% of participants were illiterates. Out of the total 330 postmenopausal women, 50.91 were homemakers. Out of the total 330 postmenopausal women, maximum number of participants were married (87.88%), 9.39% women were widows, 2.12% women were separated, 0.60% were unmarried.

About half of the women were from nuclear families (50.30%), followed by joint families (44.85%) and 4.85% women were staying alone. In terms of socio-economic status, majority of the study participants belonged to class III (29.09%) and class II (23.64%) followed by class I (20%), class IV (16.06%), and class V (11.21%). In this study, 65.45% women were vegetarians, while 43.64% were non-vegetarians [Table 1].

In the present study, the proportion of women with menopause age ≤45 years was higher in urban areas (73.56%) as compared to the rural areas (45.08%). The odds of developing early menopause (≤45 years) among urban women were 3.39 times higher than the rural women [OR: 3.39; 95% CI: 2.12-5.43]. Among married females, odds of developing early menopause (≤45 years) were 4.19 times higher as compared to unmarried, widowed, divorcee and separated females. Among the low socio-economic status (Class IV and V) women, the odds of developing early menopause (≤45 years) were 2.08 times (95% CI: 1.27-3.41) higher as compared to high socio-economic status (Class I, II & III) according to modified BG Prasad classification [Table 2].

The odds of developing early menopause (≤45 years) among women with BMI ≤ 29.99 Kg/m² were 2.64 times (95% CI: 1.22-5.70) higher as compared to women with a BMI of ≥30 Kg/m² . The odds of developing premature or early menopause among women with any kind of addiction were 64% lower than those with no addiction (0.36; 95% CI: 0.20-0.64). Vegetarian women (42.59%) and non-vegetarian women (42.10%) did not show any significant variation in developing early menopause (≤45 years). Exercise did not emerge as a predictor for early menopause (≤45 years) among women [Table 3].

The odds of developing early menopause among women who attained menarche at the age ≤13 years were 52% lower than those who attained menarche at age >13 years (0.48; 95% CI: 0.31-0.77). The odds of developing early menopause among women whose age at first delivery was <22 years were 85% lower than those whose age at first delivery was ≥22 years (0.15; 95% CI: 0.06- 0.39). The odds of developing early menopause (≤45 years) among women with parity ≤3 were 3.14 times (95% CI: 1.68-5.85) higher as compared with women having parity >5. Age at last delivery and history of contraception were not found to be associated with the natural menopause age [Table 4].

Discussion

In this study, the mean age of the study participants was found to be 52.71±5.27 years. Vinker S et al. (2003), Moon-Soo Lee et al. (2010), Rahman SA et al. (2010), and Dutta R et al. (2012) in their study reported the mean age of women as 60.4 years, 51.04 years, 50.83 years and 50.20 years, respectively.^5-8 In the present study, majority (61.21%) of the study participants were illiterates, while the remaining 38.79% were literates. Geeta R et al. (2013) and Khan S et al. (2016) reported 30% and 80.6% of their study participants to be illiterates, respectively.^9-10 In terms of occupation, in the present study, majority of the participants were house makers (50.91), which is similar to the findings of Rahman SA et al. (2010) and Geeta R et al. (2013) who reported 46.1% and 59% of the respondents to be housemakers, respectively.^7,9 Khan S et al. (2016) concluded that 35.8% of the participants were from low socio-economic class.¹⁰ In the present study, majority of the females were married or living as married (87.88%), followed by widowed (9.39%), separated (2.12%) women. A study conducted by Vinker S et al. (2003) found 75% percent of the women participants to be married, and 17% were widows.5 Rahman SA et al. (2010) and Geeta R et al. (2013) reported that 71.9% and 78% of the study participants respectively were married.^7,9

In the present study, the mean age at natural menopause was found to be 45.65±4.44 (SD) years. Dutta R et al. (2012) found the mean age at menopause to be 44.49 years.8 Chuni N et al. (2011) conducted a study among the Nepalese women and reported the mean age of premenopausal women as 45.1 years.¹¹ The variation in menopausal age could be due to the differences in methodology, race, lifestyle. The probable reason for relatively higher age at menopause reported in developed countries could be attributed to contrasting socio-cultural, climatic and geographical factors. Also, racial and genetic differences could be a contributing factor in deciding the average age at menopause.¹²

In our study, among 64.28% of the women belonging to lower socio-economic class, menopause occurred before the age of 45 years. Kapoor P et al. (2009)¹³ found that women who belonged to middle class families had a late onset of menopause (45.47 years) compared to women from poor socioeconomic status (42.13 years). This study concluded that socioeconomic status affects the age of onset of menopause. The reason behind low socioeconomic status being associated with early menopause could be due to lack of proper nutrition, and also, poor socio-economic conditions predispose to stress and other physical and psychological problems which might result in early menopause.¹³

In present study, statistically significant association was found between residence of participants and age of menopause. Urban women were found to attain menopause at an early age.

Sarkar Amrita et al. (2014) conducted a cross-sectional study and found that the mean age at menopause was higher in rural areas compared to urban and urban slums of the district.¹⁴ Reason behind this could be that urban women are educated and more aware of menopausal symptoms, and thus can easily recognize the symptoms.

The present study concluded that heavier women attained menopause at a later age than women with normal BMI. Maru L et al. (2016) conducted a cross sectional study and found that as the BMI increased, the age of menopause also increased. Thus, higher the BMI, higher was the age of menopause and these values also showed a definite statistical correlation. The possible explanation for this could be that the production of estrogen in adipose tissues is greater in more obese women resulting in higher levels of circulating estrogens, thereby making a larger reproductive span.¹⁵

Suggestions/Recommendation

Poor socio-economic status and BMI were found to be significantly associated with early menopause. Thus, it can be recommended that eating a nutritious diet rich in fruits, vegetables, and protein, drinking plenty of water, getting regular physical activity and yoga may provide relief from menopause symptoms. Calcium and vitamin D are linked to good bone health, and therefore it is important to have a diet rich in calcium and vitamin D. It is recommended to maintain a healthy BMI. The trigger foods such as caffeine, alcohol, and sugary or spicy foods can be excluded from the eating habits to avoid problems related to menopause such as hot flashes, night sweats, and mood changes.

Conclusion

The present study established that area of residence, marital status, socio-economic class, BMI, history of addiction, age at menarche, age at first delivery and parity are associated with the natural menopause age, thus suggesting the possibility of social, lifestyle, and reproductive factors impacting the menopausal age.

Conflict of interest

Nil

Source of funding

None