The factors associated with the quality of life among postmenopausal women

Objective The present work aimed at determining the prevalence of menopausal symptoms and factors associated with the Quality of life among postmenopausal women. Materials and methods This cross-sectional work was carried out on 270 postmenopausal females referring to health centers of Hamadan city chosen by stratified random sampling. A questionnaire of the Menopausal Quality of Life Questionnaire (MENQOL) was used as the data collection method. Although, the Mann–Whitney test and the Kruskal–Wallis tests were used to compare MENQOL item scores. The significance level of statistical tests was regarded as less than 0.05. Results The mean MENQOL Score in menopausal was 2.45 ± 1.04. Also, vasomotor symptoms had the highest score, and sexual symptoms had the lowest score rather than other dimensions. There was a significant association between the total menopausal quality of life score and job, economy status, smoking, exercise, supplemental Omega-3 s intake, and Postmenopausal stage (p < 0.01). As smokers, women had increasing levels of bother experienced from the MENQOL symptom than non-smokers (mean = 3.67 ± 0.85 vs. 2.36 ± 0.99; p < 0.001). While the MENQOL scores for menopausal females who exercised more often (mean = 1.56 ± 0.7) had lower than those who exercised less than 3 times per week (mean = 3.27 ± 0.9; p < 0.001). However the lowest score was menopausal females who had taking supplemental Omega-3 s than those who hadn't taken it (mean = 2.15 ± 1.06 vs. 2.65 ± 0.97; p < 0.001). Though women who had postmenopausal stage less than 5 years stage (mean = 2.28 ± 0.87) had significantly lower MENQOL scores from those who had postmenopausal stage 5 or more years (mean = 2.63 ± 1.16; p < 0.001). Conclusion Based on the results, vasomotor symptoms were the most dominant symptom. Therefore, it is necessary to improve physical activity levels, focusing on job status, recommend taking an omega 3 s supplement, and planning education and promotion intervention for cessation or prevention of smoking among postmenopausal women to increase the MENQOL is essential.


Introduction
Due to a decrease in the estrogen level of blood, menopause causes several symptoms and complications in women, including termination of reproductive capacity resulting in the complete cessation of ovarian function [1,2], vasomotor instability, decreased psychological function, forgetfulness, and vaginal and urinary tract infections [3]. Regarding cultural and ethnic differences, the severity and frequency of these symptoms vary in different countries [1,4]. Factors such as genetics, dietary habits, level of activity, and daily exercises cause differences in the natural age of menopausal in various communities.

Open Access
*Correspondence: jormand69h@gmail.com Low self-efficacy, extensive cultural conflicts, and socioeconomic inequalities, belief and gender inequalities, knowledge of the menopausal process, and stressors are the most significant factors influencing the menopausal Quality of life (QOL) [5]. As a result, vasomotor symptoms show a higher prevalence in African American and Western women than Asian women [6].
The World Health Organization (WHO) has defined the QOL as people's insights into their life status within the value and cultural systems where they live and concerning their expectations, goals, concerns, and standards [7]. The multidimensional QOL has been accepted nowadays [6]. Changes in life expectancy have led to an increase in post-menopausal life expectancy in women. Each woman spends at least one-third of her life during the menopausal period [8]. Statistics show an increasing number of postmenopausal women worldwide. In 1998, more than 477 million women were living in the postmenopausal period, and this rate will reach 1.1 billion people by 2025 [9]. According to some newer statistics in the US, 6000 people reach menopausal age every day, and about 50 million will be menopausal over the next decade. Iran is also expected to have about 5 million women with menopausal by 2021, leading to demographic changes and population aging [10].
The mean age of menopausal in Iran is lower than that in other countries due to several factors. Based on the results of various studies in Iran, the QOL of menopausal females has been reported at a moderate level [11,12]. Women make up half of Iran's population. Therefore, gaining information and knowledge of their conditions in various dimensions and planning to reform their conditions to affect society and family health seems necessary [13]. Also, given the role of women as the key members of family health and transmitting the model of education and promoting a healthy lifestyle to the next generation, acquiring knowledge of this period's symptoms and enhancing their QOL is of great necessity [5,14]. Therefore, the current work was conducted to assess the Factors related to MENQOL among postmenopausal women in the health center of Hamadan City, Iran.

Study type
The current descriptive-analytical cross-sectional work was performed on 270 women aged 45-60 years covered by Hamadan health centers in 2018.

Participants
Using the data of previous studies [15] and the formula for determining the sample size [16], the minimum sample size was determined at 250 people. Considering 5% error and 80% power and considering the effect of cluster sampling design, the sample size was determined to be 270 postmenopausal women. In the present research, the participants were selected using the stratified sampling method. Accordingly, after listing health centers in Hamadan, some of these centers were selected using a cluster sampling method. Then, after gaining permits from the centers' authorities, the samples were selected from the population covered by each center. Finally, some women aged 45-60 years covered by the centers were selected, and the data were collected. The inclusion criteria were being 45-60 years, having normal menopausal, living in Hamadan, lack of alternative hormone therapy in the past six months, no history of hysterectomy, and lack of known systemic illness. The exclusion criteria also included non-responding to all items of the questionnaire and having any physical and mental illness based on their self-report.

Statement
All methods were performed in accordance with relevant guidelines and regulations. The word informed consent was obtained from all women; they were informed about the confidentiality of the information and the project's purpose, and only if they would like, they were enrolled in the study. The Ethics Committee approved this study with all consent process at Hamadan University of Medical Sciences.

Survey questionnaire
The data collection tool used in this study consists of two parts completed by the women through the self-reporting method. The first part includes demographic information such as age, education level, economic status, marital status, smoking, job, physical activity, and supplemental Omega-3 s intake. Also, the second section includes the Menopausal Quality of Life Questionnaire (MEN-QOL). MENQOL designed by Hilditch et al. [17,18] that assesses the QOL in 4 dimensions: (1) physical dimension with 16 questions (questions 11-26); (2) the psychosocial dimension with 7 questions (questions 4-10); (3) the sexual dimension with 4 questions (questions 27-29); and (4) vasomotor dimension with 3 questions (questions 1-3), respectively. This scale, which also was used in this study, is adopted to the Persian language and is appropriate for Iranian culture [17,19]. The validity and reliability of the questionnaire have been confirmed in several similar studies. For example, the reliability of the MENQOL questionnaire was assessed using the test-retest based on intraclass correlation coefficients (ICCs). The coefficients were 0.79, 0.68, 0.92, and 0.77 for the psychological, physical, sexual, and vasomotor domains, respectively [6]. This questionnaire was on a seven-point Likert scale ranging from 0 to 7. A "zero" is identical that the woman has not experienced this specific symptom in the previous month; Score "one" demonstrates that the woman experienced the symptom, but it did not bother her; Scores "two" through "seven" demonstrate an increasing level of the bothering symptom, so that these scores indicate increasing levels of bother experienced from the symptom and correspond to the ''1'' through ''6'' checkboxes on the MENQOL [6,20]. It is essential to be mention, with increasing MENQOL scores, levels of bother experienced from the symptom are increased as well.
According to the definition of WHO, menopausal health was considered menstruation cessation without medication for at least 12 months [4]. Before the study, necessary explanations were provided for the subjects regarding the study's objectives, and their informed consent was obtained. The subjects were selected and included in the study in terms of exclusion and inclusion criteria. The demographic characteristics questionnaire and QOL questionnaire of postmenopausal females were completed through a face-to-face interview.
The duration of the interview was around 25-30 min.

Analysis of statistical data
SPSS V.23 was used to analyze the collected data. The Mann-Whiney test and the Kruskal-Wallis test were used to compare different dimensions of QOL according to individual characteristics. The significance level of statistical tests was regarded as less than 0.05. The Kolmogorov-Smirnov test showed that data were not normally distributed, the Mann-Whiney U test and the Kruskal-Wallis test were used to compare MENQOL item scores.

Demographic characteristics
The mean age of the women was 52.19 ± 3.98 years with a range of 45-60 years old. About 25.2% had an elementary education and 5.6% have university education; 77.8% were married and 14.8 were widow; about 11% had Clerk and 88.9% were housewives; 7.4% were smoking, and 59.6% had medium economic status; 47.8% usually exercise 3-5 times a week; 38.9% were taking supplemental Omega-3 s; 50.4% had been postmenopausal for less than 5 years and 40.6% for more than 5 years. Other demographic and characteristics of participants are presented in Table 1.

The menopausal quality of life, and associated factors
According to the association between Quality of Life and demographic variables, there was a significant association between the total QoL score and job, economy status, smoking, exercise, supplemental Omega-3 s intake, and postmenopausal stage (p < 0.01). As smokers, women had increasing levels of bother experienced from the symptom than non-smokers (mean = 3.67 ± 0.85 vs. 2.36 ± 0.99; p < 0.001). While the MENQOL scores for menopausal females who exercised more often (mean = 1.56 ± 0.7) had lower than those who exercised less than 3 times per week (mean = 3.27 ± 0.9; p < 0.001). However the lowest score was menopausal females who had taking supplemental Omega-3 s than those who hadn't taken it (mean = 2.15 ± 1.06 vs. 2.65 ± 0.97; p < 0.001). Though women who had postmenopausal stage less than 5 years stage (mean = 2.28 ± 0.87) had significantly lower MENQOL scores from those who had postmenopausal stage 5 or more years (mean = 2.63 ± 1.16; p < 0.001). Besides, there was a significant association between the vasomotor dimension of MENQOL and economy status, smoking, exercise, supplemental Omega-3 s intake (p < 0.01).

Frequency distribution and scores of menopausal items
Generally, the most dominant symptom, reported by 91.1% of the sample, was aching in muscles and joints ache. Besides, vasomotor symptoms with 2.80 ± 1.94 had the highest score, and sexual symptoms, with 2.12 ± 1.79 had the lowest score among the other dimensions. The mean Score of MENQOL in menopausal women was 2.45 ± 1.04. In the other words, we found that vasomotor symptoms had the highest mean scores and sexual symptoms had the lowest scores in all domains (Table 3).

Discussion
The present work was performed to determine the prevalence of menopausal symptoms among postmenopausal females and factors associated with the Quality of these women's lives in Hamadan city. Based on the obtained results, the lowest symptoms belonged to the sexual dimension, which is in line with the outcomes of the study conducted by Chedraui et al. and Parsa et al. [21,22]. So, it can be stated that enhancing information and knowledge alongside high education level, increasing support and counseling [10], and improving adaptation and adaptive behaviors in postmenopausal periods may improve the MENQOL in the sexual dimension among this group of menopausal women. The findings indicated a significant association between the total QoL score and job, economy status, smoking, exercise, and supplemental Omega-3 s intake. Consistent with the results of the researches reported that the MEN-QOL was associated with the job [6,23,24]. In general, employed women may have better access to health care services and adapt to postmenopausal symptoms. On the other hand, based on the results of Fallahzadeh et al., being employed, and high social interaction with other people can reduce the physical symptoms of menopausal [6]. Overall, it seems that menopausal women are more likely to have menopausal complications because of the stresses of working at home. So, it may be necessary to design and implement effective educational and promotional interventions to improve the sense of usefulness in menopausal women.
The poor economic status may cause the severity of menopausal symptoms. In this sense, Li et al. have previously reported low economic status as the main factors contributing to the incremented severity of menopausal symptoms or a longer duration of the menopausal symptoms [25]. His finding is also similar to that reported by Fallahzadeh et al. [6]. However, being employed and having high-income levels may be increased access to healthcare or the level of coping mechanisms for menopausal symptoms.
Nicotine dependence and smoking may reason the severity of menopausal Symptoms amongst postmenopausal women Smokers. These results are consistent with the funding of Copeland et al. [26]. However, cigarette smoking and hookah smoking have antiestrogenic properties, which may health risks associated with menopause symptoms.
A high physical activity level may reduce the menopausal symptom. This funding is similar to the results of other studies [27,28]. Concerning, exercise has long been proven to be as effective as relaxation and meditation, as well as aerobic exercise, induces weight loss and increases in their hot flashes' severity and reductions in the risk of memory problems. It should be noted that exercise and physical activity in this group of women leads to increased social interactions, and group aerobic exercise leads to improved mental health and Quality of life in this group of people. So, having exercise play improvement of women's Quality of life in menopausal women.
There was an association between menopausal symptoms and supplemental Omega-3 s intake in postmenopausal women. Saimin et al. reported increasing the quantity and frequency of fish consumption will reduce the severity of menopausal symptoms [29]. Studies showed that supplemental omega-3 s could improve overall health conditions [30,31]. So, design and planning intervention programs for a healthy lifestyle [32], for the improvement of women's Quality of life in menopausal women seems to be essential.
Additionally, in the psychosocial, physical domains, women who were in the postmenopausal stage less than 5 years ago had lower scores than those who were in the postmenopausal stage more than 5 years ago. Also similar to that reported by Fallahzadeh et al. and Karmakar et al. [6,33]. Nevertheless, some women experience symptoms earlier during the time since menopause while some experience them at a later time.  [6,15,[34][35][36][37]. Moreover, Reproductive hormones seem to play a significant role in this regard. In this period, dramatic changes occur in hormone levels, including reduced severe estrogen, which results in Vasomotor symptoms (VMS) such as hot flushes and night sweats. Some studies have reported an increase in the frequency of vasomotor symptoms, which is consistent with the current work results [38].
Following the outcome, physical symptoms were the most experienced and complained factors, among other dimensions in the postmenopausal period. In agreement with the findings in the current work, Ceylan et al. indicated that the most frequently experienced symptoms during this period were aching muscles and joints [39]. It seems that factors such as reproductive hormones play a major role in this regard. As a result, dramatic changes in hormones, including a severe reduction in estrogen, occur, leading to physical symptoms during this period. This result is in accord with paying attention to menopausal in health care services programs to enhance women's life expectancy seems to be useful in this field.
The major limitation of the present study is its selfreporting and descriptive cross-sectional nature. Therefore, it is recommended to investigate the subject of the present study as a longitudinal or trial study. Given the complexity of MENQOL dimensions, a qualitative study of menopausal phenomena and understanding other related factors can also be helpful.

Conclusion
In general, the results of the present work revealed that vasomotor symptoms were the most dominant symptom. Therefore, increased life expectancy among these women will be possible by designing and implementing effective educational interventions. It is necessary to improve physical activity levels, particularly in developing countries, focusing on job status to decrease unproductive feelings, encourage social interaction skills, and enhance economic status. Simultaneously, recommend taking an omega 3 s supplement and planning education and promotion intervention for cessation or prevention smoking among postmenopausal women to increase the MEN-QOL is essential.