Health-Seeking Behaviors and Treatments Received for Menopause Symptoms: A Questionnaire Survey among Midlife Women Attending Primary Healthcare Clinics in Malaysia

Menopause is a permanent cessation of menstruation for 12 consecutive months due to the loss of ovarian function. During midlife women experience menstrual irregularities and menopausal symptoms [1]. Hot flushes and night sweats were reported by up to 80% of midlife women among European women [1, 2]. Other menopausal symptoms are mood changes, sleep disturbances, heightened anxiety, fatigue, vaginal dryness, dyspareunia, joint pains, bladder symptoms, anxiety, and skin changes [2]. Menopausal symptoms vary across geographies. Among Asian midlife women frequently reported menopause symptoms are joint and muscular pain and fatigue [3, 4, 5]. Cultural background and religion are known to influence the perception of menopausal symptoms and treatment-seeking behavior [4, 6]. Asian midlife women have a positive attitude towards menopause, and they tend to accept menopause as a rite of passage. As a result, they are left with unmet physical, emotional, and psychosocial needs. They are also unprepared to receive treatment for menopausal symptoms [7, 8]. Current guidelines recommend Hormone Replacement Therapy (HRT) for menopausal symptoms [9, 10, 11], however, there is a decline in the prescriptions of HRT by healthcare providers (HCP) due to the ongoing debate surrounding the benefits versus adverse effects of HRT following the Women’s Health Initiative report [12]. Despite the more recent evidence about the benefits of HRT in reducing the risk of cardiovascular events and prevention of osteoporosis the usage of HRT has continued to decline [12, 13]. Given the benefits of HRT, it is important to screen the midlife women attending primary care clinics to make treatment decisions [14]. To provide advice about HRT to midlife women it is important to understand their current treatment-seeking behaviors i.e., types of HCPs consulted, and treatments received or preferred for menopausal symptoms. Such information is needed to develop and counsel women with menopause symptoms, and develop referral guidelines for providing evidence-based treatments from appropriate HCPs [15].

Up to 50% of midlife women choose Complementary and Alternative Medicine as a treatment choice for menopausal symptoms [16, 17, 18]. However, caution is needed to prescribe treatments such as aromatherapy, massage, acupuncture, and herbal medication evidence about their effectiveness [19, 20] is very limited. Malaysian studies have reported that midlife women are often reluctant to discuss menopausal symptoms [21, 22]. Survey studies from Klang Valley and Seremban state have reported that the proportion of women having menopausal symptoms seeking HCP consultation and treatment is sub-optimal [5]. These studies have reported descriptive results about the type of HCP consulted and the treatment received from them. However, the decision to seek consultation is also driven by the number of menopausal symptoms, and their severity [23] which were not assessed in previous Malaysian studies and these studies were done in smaller geographies in West Malaysia only [5, 21, 22]. We aimed to cover a wider geographic area in Malaysia by including East Malaysia and study the association seeking HCP consultation for menopausal symptoms with socio-demographic factors, number of menopausal symptoms, and comorbid conditions. We used a proposed menopause quick-6 (MQ6, [M]) for screening midlife women for menopausal symptoms to assist in HRT decisions [14] at primary care clinics. We assessed the menopausal symptoms, treatment-seeking behavior, treatments received, and factors associated with seeking consultation from an HCP for menopausal symptoms among midlife women attending primary healthcare clinics.

Our survey using a proposed quick assessment tool translated and validated into Malay language identified joint pains, menstrual changes, and hot flushes as common menopausal symptoms among midlife women attending primary care clinics. About a third of midlife women, we surveyed had experienced at least one menopause symptom consulted an HCP. Doctors at public and private clinics were preferred over medical specialists. Notably, treatments were prescribed to only a third of women who had consulted HCP. Vitamins, massage, and traditional medicine were mostly prescribed by the HCPS for the treatment of menopausal symptoms, and HRT was the least prescribed treatment.

The common symptoms reported by midlife women in our study are comparable to those reported by previous Malaysian studies [5, 21, 22, 24]. Nevertheless, it should be noted that 3 of these studies [5, 24] used the Menopause Rating Scale (MRS) [25] while Dhillon et al. [22] developed their questionnaire in the Malay language. MRS used in Malaysian studies were not translated and validated into Malay language but a validated Malay version of MRS has become available [26]. The number of items in MQ6(M) is less than MRS, yet it captured the common menopausal symptoms prevalent among midlife Malaysian women. These findings support the utility of MQ6(M) which is purported to be a quick screening tool for treatment decisions in primary care [14]. As MQ6(M) can identify menopause symptoms among midlife women attending primary care clinics studying their health-seeking behavior is important to provide further advice on treatment. Providing evidence-based treatment would improve the quality of life of midlife women who are going through the phases of menopause.

Our study showed that the proportions of midlife women with at least one menopausal symptom seeking consultation for menopausal symptoms were comparable to two Malaysian studies [5, 21]. A community survey from Klang Valley did not report about the type of HCP consulted but the study from Negeri Sembilan reported that a higher proportion of women had consulted pharmacists, and traditional practitioners than our study [21]. The types of treatments received by the midlife women in our study were mostly vitamins and alternative medicines as in other Malaysian studies [5, 21]. HRT was prescribed for only a small proportion of midlife women. In all Malaysian studies, the proportion of women who were treated with HRT was low relative to those in the USA despite their decline over time [27]. In a survey from Ipoh, Malaysia more than a third of women had received various types of alternative medications for menopausal symptoms [28]. Our study highlights those women with menopause consulted diverse HCPs and received mostly symptomatic relief for menopause symptoms. These findings also concur with menopause treatments received by midlife women in the Asian Menopause Survey [29]. Treatment of menopause symptoms with vitamins and traditional medicines is not evidence-based. Evidence-based treatment such as HRT also has long-term health benefits [9, 10]. The reason for not seeking consultation or receiving treatment could be due to women’s perceptions about menopausal symptoms as they consider menopause a passing phase [8] or that menopause did not affect their quality of life [5]. These results are not surprising since qualitative studies have revealed that women prefer non-medical treatments to deal with menopausal symptoms [8]. It has also been debated that some HCPs are reluctant to treat midlife women with HRT [30].

It is important to study the factors that determine a midlife woman’s decision to seek consultation. Previous studies have tested the association of treatment-seeking behavior with sociodemographic factors only [5, 21]. Therefore, we considered both menopause-related and health-related factors to assess factors associated with seeking consultation from an HCP. We found that having menstrual changes, attainment of menopause, and higher MQ6(M) score were associated with seeking consultation. However, the presence of medical conditions and gynecological also were associated with seeking consultation, possibly a residual confounding effect. Perhaps the participants were midlife women recruited from primary care clinics who also had coexisting medical and/or gynecological conditions and hence these factors were also associated with seeking consultation. This finding underscores the need for screening midlife women for menopause in addition to other chronic conditions. In this direction, MQ6(M) has the potential to be a quick screening tool to make treatment decisions at primary care settings.

Though we studied women from different sites in both peninsular Malaysia and East Malaysia, the midlife women were recruited from primary care clinics. Hence the sample is not representative of the entire Malaysia and that of the general population. Our survey instrument MQ6(M) was used only to indicate the presence or absence of symptoms but not their severity. Seeking consultation with HCP was asked in general for menopausal symptoms and not for specific symptoms. Therefore, we cannot ascertain for which symptoms consultation was sought and the symptom-specific treatments. Community-based surveys and detailed questions on care-seeking and treatments received for each menopausal symptom would provide better insights into current health-seeking behaviors of Malaysian midlife women about menopause symptoms.

MQ6(M) can identify menopausal symptoms among Malaysian midlife women. Women having menopausal symptoms did not consult an appropriate HCP and treatments received were mostly vitamins and traditional medicines. Midlife women at primary care clinics should be screened with MQ6(M) and be counseled by HCP to receive evidence-based treatments such as HRT for a better quality of life and long-term health benefits.

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