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Hephzibah Kirubamani: Knowledge, awareness, attitude towards menopausal symptoms & hormone therapy in urban & rural population


Menopause is a permanent and physiological event which occurs due to cessation of the ovarian function when clinical diagnosis is confirmed, following stoppage of menstruation for twelve consecutive months. Menopause normally occurs between the ages of 45 and 50 years, the average age in India being 46.2 years. Indian women attain Menopause earlier than those in western countries. Cessation of ovarian activity and a fall in the oestrogen level to 10-20 pg/mL occurs and this may predispose women to get menopausal health problems like vasomotor symptoms, urogenital atrophy, osteoporosis and fracture, cardiovascular disease, cerebrovascular disease, psychological changes, sexual dysfunction, dementia and cognitive disease.1 Menopause is not an illness, but it will cause morbidity and mortality which will increase public health burden.2 To cope with these changes, women should have appropriate understanding of the physical, mental, social and psychological changes which occurs during menopause. Identifying the women's perception of menopause has an essential role in the development of accurate and appropriate programs to promote their quality of life. To make a continuous change in behavior, improving knowledge about menopause symptoms and positive attitude towards Menopausal Hormone Therapy is very useful.3 Health education may help to achieve these changes. A majority of the Indian population reside in rural areas where the availability of a good health care system is sparce and menopausal complaints are likely to be ignored. To minimize the postmenopausal morbidity prevention, is essential and the most important step in prevention is health education which is a tool for good public health.

Aim of the study

To assess the extent of knowledge and attitude towards Menopause symptoms among urban and rural women.

To determine their attitude towards Menopause Hormone Therapy among urban and rural population.

To determine how many women resort to Menopause Hormone Therapy among urban and rural population.

To compare their knowledge and awareness about Menopause Symptoms, their attitude towards Hormone Therapy before and after Health Education among urban and rural.

Materials and Methods

A prospective cross-sectional, quasi experimental study was conducted at some urban areas of Chennai city namely Alandur, Guindy and Adayar and in some rural areas of Chennai, namely Thirumazhsai-Thiruvalluar District and Kuthampakkam-Kanchepurum District. The study was conducted after obtaining the prior approval of the Institutional Ethics Committee. After obtaining an Informed Consent, the women were interviewed using a validated structured questionnaire which has three parts, namely, their knowledge about menopause symptoms, their attitude towards Menopause and their knowledge about the usage of Menopausal Hormone Therapy. Health education was imparted to these women regarding menopausal symptoms, its long term complications and the need for Menopausal Hormone Therapy and about lifestyle modification. The same group of women were asked to answer the very same questionnaire during a followup visit to assess the improvement in their knowledge and attitude towards the use age of Menopausal Hormone Therapy. The data so obtained was entered in MS Excel and the SPSS (Statistical Package for Social Sciences) Software Version 21.0 was used for its analysis. Simple Proportions was calculated. Pair T test was used for statistical analysis.


770 women agreed to participate in the study. Figure 1 shows the age distribution among the Urban and Rural in the study population. Among urban women, 11.16% of the women who participated were between 40-45 years of age, 43.63% were between 46-50 years, 32.46% were between 51-55years and 12.72% were between 56-60 years. Among rural women 5.19% of the women were between the age of 40-45 years, 44.41% were between 46-50 years, 34.02% were between 51-55 years, 13.24% between 56-60 years and 3.11% between 61-65 years. The Mean Age of menopause in both groups was 48.50 years.

The educational status of the study population is depicted in Figure 1. A substantial proportion of the rural women (75.84%) did not have any formal education. 18.70% of the women had primary education, 5.45% of the women had high school education. Among urban women, 55.32% were undergraduates and 44.67% were postgraduates. Figure 1 shows the Marital Status among urban and rural women. Among urban women, 68.83% were married, 9.80% were single, 12.46% were widows and 8.83% were divorced. Among rural women 83.37% were married, 13.50% were widows and 3.1 0% were separated.

Table 1illustrates the comparision of the knowledge these subjects had about Menopausal Symptoms ‘before’ and ‘after’ Health Education. Based on statistical analysis, both urban and rural population showed a marked increase in knowledge about menopausal symptoms. Among urban women, the T Value was 2.40 and the p Value was 0.016 and in the case of rural women the statistical figures were 1.32 and 0.105 respectively. Change in awareness about long term complications among urban and rural women is represented in Table 2. The statistical analysis underlines the fact that the women in both the urban and rural population have understood the implications of all the long term menopause complications after imparting health education. Improvement in awareness about joint pain, both in urban and rural women, showed a T Value of 0.596 and a p Value of 0.67. The corresponding values with respect to Muscle Weakness were 0.582 value 0.78 respectively. In the case of Osteoporosis, T Value was 0.685 and p Value 0.69. In breast carcinoma, they were 0.558 and 0.68 and in post-menopausal bleeding, they were 0.689 and 0.69 respectively.

Positive attitude about menopause generally comes as a woman ages. Menopause is natural, menopause is good, no more menstruation, no fear of pregnancy and the feeling of maturity are similar in both urban and rural population.

Table 3 shows that, among both urban and rural women, there is significant change in their negative attitude towards menopause after health education with a T Value of 0.02 and a p Value of 0.40 in rural areas and T Value of 01.90 and a p Value of 0.098 in urban areas. Both urban and rural women have understood that Menopause Hormone Therapy should be given to symptomatic women. Their attitude towards Menopause Hormone Therapy in both groups had changed significantly with a T Score of 0.582 and a p value of 0.789 (Table 4).

Out of 770 women, 36 women (9.35%) had MHT. For 58.33% of the women, (Figure 2) their source of in formation about Menopause Hormone Therapy was through doctors. Figure 3Depicts the statement by Menopause Hormon Therapy users. 58.33% women using Menopause Hormone Therapy for surgical menopause and 41% of the women following natural menopause out of which, 16.70% used Menopause Hormone Therapy for vaginal dryness and 25% used it for hot flush. All of them exhibited 100% relief of their symptoms. Previously these women were ignorant about the different routes of therapy that was available to them and they had never tried alternative therapy. After they were imparted health education, they were satisfied and said they will recommend their knowledge to their friends when they developed any such symptoms.

Figure 1

Shows distribution of age, educational status and marital status between rural and urban
Table 1
Menopause Knowledge Urban Rural Conclusion
Before After Before After Based on Statistical analysis both urban and rural population showed increase in knowledge about menopausal symptoms
Depressed 317 380 0 85
Irritable 312 381 0 109
Forget fullness 335 381 34 123
Anxiety 323 374 46 146
Sweaty Flush 305 373 0 139
Sleep Disorder 340 382 44 171
Urinary Problem 277 378 69 162
Sexual Disinfection 323 377 41 165
Vaginal Dryness 316 365 54 149
Decline of Oestrogen 316 379 0 81
Abdominal Obesity 266 373 0 108
Facial Hair 208 354 0 72
Hair Thinning 300 373 0 87
T- Statistics 2.4 1.32
P- Value 0.016 0.105

Comparision of knowledge about menopausal symptoms ‘ Before’ and ‘ After’ health education

Table 2

Comparison among urban and rural about long term complications ‘After’ health education

Long Term Complication Urban Before Education Urban After Education Rural Before RuralAfter T Statistics P Value Conclusion
Joint Pain 277 356 92 208 0.596 0.67 The Statistic shows that both the women population, Urban And Rural, has understood about the long term Menopause complications after Health Education was imparted.
Muscle Weakness 262 350 0 48 0.582 0.78
Osteoporosis 293 382 0 58 0.685 0.69
Breast Cancer 316 373 15 54 0.558 0.56
Postmenopausal Bleeding 279 373 23 100 0.689 0.69
Figure 2

Source of Information for those who had MHT

Table 3

Changes in negative attitude among rural and urban women after education

Menopause Rural Urban Conclusion
Before After Before After Significance Observed.The P Value based on the two dependent Population testing, shows that there is astatistical significance in thenegative attitudinal change amongrural population after education.
Less attractive 187 127 277 150
No sexual life 150 96 250 62
Period of psychological & emotional changes 23 85 31 46
Feel lonely 27 77 15 19
T-Statistic 0.02 01.9
P-Value 0.4 0.098

Urban women have a negative attitude when compared to rural women. But, after health education about lifestyle changes in exercise, diet, involvement in religious and social activity, their attitude changed towards the positive side.

Table 4

Attitude towards MHT in both urban and rural women

MHT Urban Before Education Urban After Education Rural Before RuralAfter T Statistics P Value Conclusion
MHT can be given for all menopausal women 358 261 0 62 0.596 0.67 The Statistic shows that both the Urban And Rural population had understood the need of MHT for symptomatic treatment after Health Education was imparted.
MHT mostly to be avoided for asymptomatic women 292 384 0 46 0.582 0.78
MHT has side effects &complications 293 382 0 55 0.685 0.69
Alternative methods better For symptoms 373 316 54 15 0.558 0.56

Out of the 770 women, 36 women (9.35%) had MHT. For 58.33% of the women, their source of information was through doctors.

Figure 3

Statement by MHT users

58.33% women used MHT for surgical menopause. Common complaints among natural menopause women was vaginal dryness and hot flushes.


In this study, the mean age of menopause in both urban and rural women was 48.50 years, which is lower than that of western countries. Menopause age is different in different countries. In Italy the mean age of menopause is 51.2 years (Parazzini, Fetal)4 and in Iran 48.2 0 years (Rajaeefard, A et al.).5

In this study, 75.84% of the women from rural areas did not have any formal education. Among urban women, 55.32% were undergraduates and 44.67% were postgraduates. In the study carried out by Saima Hamid et al,6 46% were illiterate, 21% had attended universities, 8% preparatory, 16% had primary education and 9% secondary education.

Knowledge about menopause symptoms was low in the study by Leon, P et al7 which was similar to this study, where knowledge about Menopause Symptoms was almost nil among rural women compared to that of urban women. In the study conducted by Shohani, M et al,8 women were found to have little knowledge about menopause. In this study, among urban women, 9.35% of them had knowledge about Menopause Hormone Therapy since they were using it for their symptoms but in the study conducted by Memon et al,9 knowledge about Menopause Hormone Therapy was present in only 5% of the participants. In the study by Quasim M Al Shboul et al,10 awareness about Menopausal Hormone Therapy was low. In the study by Jin F,11 2-1% of the women that were studied had used hormones. Studies conducted by Leon et al12 and Donuts et al13 in Italy, showed that over 90% of the samples had a positive attitude toward menopause which is similar to this study, where, both rural and urban women showed a positive attitude.

The study by Koster A et al,14 Pan Hsien-An et al,15 stated that the major source of information in these matters were doctors which is consistent with the findings of this study. 58.33% women reported that their source of in formation for Menopause Hormone Therapy were friends and acquaintances, mother or sister, the media and doctors. In the study by Garmaznegad S et al,16 the major source of information were not doctors, but were friends and acquaintances, mother or sister, the media and finally, doctors.

Results of this study showed marked changes in the knowledge about menopausal symptoms and their attitude towards Menopause and also about the knowledge and usage of Menopausal Hormone Therapy after health education. Fahimeh Sehhatie Shafafe et al17 concluded that improvement in education about menopause enhances the capability of women to cope up menopausal symptoms.


As knowledge about menopause is less, more awareness programmes should be conducted both in urban and rural areas. By understanding the women’s knowledge and their attitude about Menopause Hormone Therapy will aids health workers to work effectively. It is important to identify women’s knowledge, attitude and their usage of menopause hormones is essential to develop accurate and appropriate programs to improve post menopausal women’s health.


I would like to thank the Director and the Dean of Saveetha Medical College for their encouragement and support. I thank profusely the women who participated in the study.

Financial support

IGCL grant from Pfizer.

Conflict of interest




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