Assessment of prevalence of vasomotor menopausal symptoms using a modified menopause rating scale(MRS) in Peri and postmenopausal women

Menopausal symptoms can often be distressing and affect the normal activities of women in their middle age. This can significantly reduce their quality of life. This study was done to assess the prevalence of vasomotor menopausal symptoms using a modified menopause rating scale (MRS) in Peri and postmenopausal women. A cross-sectional observational study was done on 100 middle-aged women (40-65 yrs) during the period January-June 2020 using the modified menopause rating scale (MRS). The mean age of the respondents in the study was 52.71 yrs. The mean age at menopause is 56 yrs. The commonly found symptoms were joint and muscular discomfort (80%), physical and mental exhaustion (65%) and sleeping problems (50%) appears to be the most commonly experienced symptoms by these women. The other symptoms are hot flushes and night sweats (46%), irritability (40%), dryness of vagina (38%), anxiety (36%), depressive mood (34%), sexual problems(30%), heart discomfort (16%) bladder problems (14%). This study showed that the typical vasomotor symptoms of menopause like sweating and hot flushes were comparatively lower than that of somatic symptoms like joint and muscular discomfort, mental and physical exhaustion in general. At the same time, postmenopausal women experienced more of urogenital symptoms, while Peri and premenopausal women experienced somatic and psychological symptoms.


INTRODUCTION
Menopause is de ined as a normal physiological process experienced by middle-aged women characterised by complete cessation of menstruation for twelve months or more (Rahman et al., 2010).
Menopause is characterised by a variety of symptoms in the following broad categories 1)vasomotor 2)physical3)psychological 4)Urogenital. The physiological basis of these symptoms of menopause through the complex is attributed mainly to the hormonal changes(mostly oestrogen deprivation)that occurs during this age. Often these symptoms can be distressing and affect the usual daily activities of women. It is also irmly proven that some of these symptoms of women can affect the quality of life (Williams et al., 2009;Chedraui et al., 2008). So it is important that women of middle age to be aware of this physiological process and the symptoms they cause as when it becomes severe, they can cause cardiovascular and bone(osteoporosis) manifestations. This study was done to check the prevalence of various symptoms of menopause among middle-aged women (40-65 years). There are var-ious tools designed for assessing the prevalence of menopausal symptoms and their severity and the degree of affection of quality of life. The modiied menopause rating scale(MRS) was used in this study (Alder, 1998;Heinemann et al., 2003).
Very few studies are done regarding the assessment of menopausal symptoms experienced by middleaged women in southern India, especially Tamil Nadu. A modi ied MRS was used in this study to assess the menopause-related symptoms among middle-aged women.

Methodology
A cross-sectional observational study was done on 100 middle-aged women(40-65 yrs) attending Saveetha medical college and hospital during the period January-June 2020 using the modi ied Menopausal Rating Scale(MRS) [ Figure 2]. The institutional review board and ethics committee of Saveetha medical college approved this study. All women who gave consent to participate in the study were included in the study. Women with pre-existing co-morbidities like heart diseases, uncontrolled hypertension and diabetes, women on hormone replacement therapy(HRT) or in ongoing treatment for cancer, pregnant and breastfeeding women were excluded from the study. The questionnaire contained three sections: Sociodemographic details of the women which included: Age, Marital status, education, occupation.
According to STRAW classi ication(stages of the reproductive ageing workshop), the menopausal status of women was assessed: Postmenopausal-Absence if menstrual bleeding in the last one year. Late perimenopausal-the absence of menstrual bleeding in the last two months. Early perimenopausal-the presence of irregularity in menstruation(7 days difference from the beginning of the cycle to the next cycle) but an absence of skipping menstruation. Premenopausal-cycle length changes present (mainly decrease in cycle length) For convenience, the early and late perimenopausal were combined as perimenopausal for statistical analysis.
Menopause Rating Scale(MRS) questionnaire containing all the 11 symptoms under four broad categories. Vasomotor and physical-hot lushes, heart discomfort/palpitation, sleeping problems and joint and muscular discomfort. Psychological-depressive mood, irritability, anxiety, mental and physical exhaustion. Urogenital-sexual problems, bladder problems and dryness of the vagina was used to assess the prevalence of menopausal symptoms.
Each of these symptoms had scoring from 0(no com- plaints) to 4(very severe). As the majority of the women were poorly educated, and they found it dificult to score the severity of the symptoms, the grading system was modi ied to present or absent to minimise the dif iculty. So this study determines only the prevalence and not the severity of the symptoms experienced. The analysis was done using SPSS software version 19.

RESULTS
One hundred women participated in the study. The mean age of participants in the study was 52.71 yrs. The mean age at menopause is 56 yrs. Among these women, 24 were premenopausal 40 perimenopausal, and 36 were postmenopausal. Majority of the participants were married(92%) and housewives (69%). 81% of the women had less than 11 years of schooling [ Table 1].

DISCUSSION
The mean of the age of menopause in this study was 56, which was slightly higher as compared to a study done by Dr.K peeyananjarassri et al., in which mean menopausal age was 48.7 yrs. But this inding lies within the normal range of menopause age(40-57 yrs) (Peeyananjarassri et al., 2006).
Menopausal rating scale(MRS) is the assessment tool used in this study. However, it was modi ied a little to make it easier for local women to understand  and reciprocate accurately. Therefore we could only assess the prevalence of the menopausal symptoms and not their severity (Alder, 1998;Heinemann et al., 2003).
In this study, symptoms like hot lushes and night sweats which are considered to be the typical symptoms of menopause were noted to be 46% when compared to a similar study done by Hardip Kaur Dhillion et al., and night sweats were experienced by 53% of the women and hot lushes by 44.6% of them (Dhillon et al., 2006) . Lorraine Dennerstein et al. did another study., showed that only 27% of women experienced typical symptoms like hot lushes (Dennerstein et al., 2000).
It was observed that vasomotor symptoms like hot lushes and sweating(night sweats) were experienced by perimenopausal women followed by post and premenopausal women. This could be attributed to the fact that hormonal luctuations(oestrogen) occur mainly during this transition period. A research done by C Travers et al. stated that vasomotor symptoms, which was assessed by the Greene Climacteric Scale, were common during the menopause transition period and remain elevated for some years in a some of the older postmenopausal women (Travers et al., 2005).
Most of the psychological and somatic symptoms which include joint and muscular discomfort, men-  It is also observed from this study that 42% of the premenopausal women experienced irritability, anxiety and sleeping problems, 37.5% of them experienced joint and muscular discomfort. This may not necessarily be menopausal symptoms. It can also be the symptoms of other health problems or symptoms of ageing. A similar study by Syed Alwi et al., also showed comparable results (Rahman et al., 2010).
Some symptoms like bladder problems, sexual problems and dryness of vagina under the urogenital category are found to be more common in postmenopausal women than pre and perimenopausal women, as stated in Table 3. Sexual problems may not be solely caused by menopause, and it can be a result of various other complex factors which needs more emphasis.
There are a few limitations of this study which has to be noted. The MRS questionnaire was slightly modi ied to make it easier for these women as they found it dif icult to grade the severity of the symptoms. The women were asked to give retrospective information about the symptoms they experienced, which increased the chance for recall bias. Another limitation of this study is that it didn't exclude the other confounding factors like a natural ageing process which could have contributed to the above symptoms.

CONCLUSIONS
This study was about assessing the prevalence of various menopausal symptoms among middle-aged women of 40-65 yrs. It showed that the mean age of menopause was 56yrs and the typical vasomotor symptoms of menopause like sweating and hot lushes were comparatively lower than that of somatic symptoms like joint and muscular discomfort, mental and physical exhaustion in general. This may be because of the tropical climatic conditions due to which the tolerance level of these symptoms is increased in women residing here. Whereas postmenopausal women experienced more of urogenital symptoms while Peri and premenopausal women experienced somatic and psychological symptoms.