Cuban Medical Literature
Comprehensive Health of Women
During Climacterium

Miguel Lugones Botell MD,*
Mauricio Córdova Armengol MD,**
Tatiana Dávalos Sarría MD***

ABSTRACT:A descriptive longitudinal study was carried out in a group of 300 women, aged from 40 to 59 years, in the climacteric and menopausal stage at different dispensaries in the 26 de Julio and Jorge Ruíz Ramírez Teaching Polyclinics from September 1 to December 31, 2001.

A questionnaire requesting the following data: age, age at menopause, marital status, signs of climacteric syndrome, some characteristics of sexuality, job, risk factor and presence of some diseases, was filled out. The chi square test was the statistical method used. The conclusions were that the average menopause age was 47.9 years. The main symptoms they presented were: hot flashes, sweating, anxiety and depression. A large group of the women did not have stable partners, predominantly the postmenopausal women. A significant group of them also had sexual difficulties, mainly due to a lack of privacy, avoidance of sexual relations, and decreased sexual drive in women around perimenopause; difficulties noted in postmenopausal women included vaginal dryness, avoidance of sexual relations, and decreased sexual drive. Most of these women work, mainly those going through perimenopause, and have workplace problems. There are important risk factors in these patients due to lack of exercise, smoking and obesity or being overweight.

Keywords:CLIMACTERICS; WOMEN'S HEALTH; RISK FACTORS; PREVENTION

INTRODUCTION

A consequence of the increased life expectancy of women is that over one third of a woman’s life takes place after menopause. Since the beginnings of the 1900s menopause has been the object of historical, literary and cultural discourse. (1) In that century, human life was prolonged until almost 80 years, giving rise to outstanding implications in the biological, psychological, social, cultural and demographic spheres, among others. Thus, in those countries regarded as economically developed, by the end of the ’90s, the population ranging from 60 to 75 years of age accounted for almost 13% of the total population and it has been calculated that by the year 2030, it shall reach 18%. On the other hand, in Latin America, the population from 60 to 75 years old represented 6%, with an expected increase of up to 14% by the year 2030. (2) These statistics show that, considering only the female population, the number of postmenopausal women has risen and, therefore, a larger part of their lifetime will happen in that stage. In general, menopause occurs between 45 and 50 years. (2)

From a phylogenetical point of view, it should be remembered that the human species is the only one that survives extensively after the reproductive stage is over.

Currently, it is believed that over 90% of the women in developed countries should pass the climacteric stage. (3) Thanks to the advances made by our public health system, we expect to have almost 4 million women reach the age of menopause. (3) This alone justifies the need to study the clinical, biological, psychosocial and other signs in these patients.

For a long time, menopause was considered to have a sudden onset, characterized simply by the disappearance of the menstrual cycles and corresponding with the end of reproductive life. Nevertheless, it is now known that climacterium begins several years before amenorrhea appears, almost by the time women reach their late 30s. (2). In this stage estrogen production by the ovaries becomes irregular and a significant hormone deficit occurs. (2). This progressive hypoestrogenic condition affects not only the reproductive organs, but also involves other functions and systems such as the general metabolism, nutritional efficiency, bone replacement, and lipoprotein synthesis. The lack of estrogen causes an impact on the cardiovascular system and blood pressure, as well as on immunological response and susceptibility to degenerative diseases. (2) On the other hand, the irregular production of estrogen by the ovaries has repercussions on the affective and emotional status, on memory and the circadian rhythms; that is, on the neuroendocrine system.

Therefore, we consider the stage of climacterium and menopause as very significant in the life of women for several reasons:

• It takes place at a time when women are still active and useful to the family and society.
• Demographic statistics demonstrate that life expectancy reaches 80 years of age, meaning there are about 30 years of useful life after menopause, with clinical and morphological differences that may, and in fact do, have effects on morbidity.
• The occurrence of chronic diseases at this stage is much higher. The most frequent are: cardiovascular diseases, stress and gynecological cancers. (4)
• Studies performed in our country show that important events take place during this stage in the family and couple dynamic, and in labor matters. (5,6)
• Some behaviors, habits and lifestyles are reinforced in this stage, such as, for example, the infrequent practice of physical exercises, an increase in weight and fat layer, and smoking. These factors are directly related to the appearance of cardiovascular diseases and other chronic diseases. (6)
• Non-transmissible chronic diseases are an important cause of premature morbidity and mortality, which can be avoided. Furthermore, the economic and human cost is extremely high.

With this approach, the importance of prevention and health promotion in this population group becomes evident. Work should be mainly directed towards limiting and, whenever possible, eliminating risk factors, for which primary health care, involving the complete basic work group is essential. For more on the basic work group, see 20 Years of Family Medicine in November's MEDICC Review .

We must emphasize that health disorders found by the family doctor in primary health care are not purely biological or psychological, but rather a complex mixture of biological, psychological, and social components; (7) since this stage of life is full of these, it is essential to have a holistic approach when treating these patients. Climacterium and menopause can never be considered isolated phenomena. The importance of this stage lies, among other things, in that the different changes that take place may affect the quality of life and life span of these patients. (8)

The above mentioned, plus the creation in our country of the Climacterics and Menopause Section of the Cuban Society of Obstetrics and Gynecology in the ’90s, the recent publication of the “Cuban Consensus on Climacterium and Menopause,” (9) the experience working with these patients, and other forthcoming considerations, absolutely justify the due priority and care women must receive during this stage, with the physician working in primary health care playing an essential role.

GENERAL OBJECTIVES

• To determine some of the characteristics related to integral health of women during climacterium.

SPECIFIC OBJECTIVES

• To identify the average age for menopause and the main climacteric symptoms.
• To determine some of the characteristics of sexuality.
• To determine the work status and possible problems related to work.
• To identify the presence of risk factors.
• To detect the presence of some diseases.

MATERIALS AND METHODS

This research classifies as a descriptive longitudinal study.

Sample

A study was carried out in 300 women with ages ranging between 40 and 59 years. They were randomly selected in different dispensaries from the 26 de Julio and Jorge Ruíz Ramírez Teaching Polyclinics during the period from September 1, 2001 to December 31, 2001. A questionnaire was filled out (Appendix 1). The patients studied were those who were in the dispensary at the moment of our visit, independent of the reason.

Studied Variables

Before filling out the questionnaire, we met with the women and gave them a detailed explanation of the objective of the study, assessed their willingness to participate or not and explained the importance of this work, as well as the need for sincerity in their answers.

Age was requested, as was age of menopause, explaining that they had to have been without menstruation for at least 12 months to consider it menopause; the main signs of the climacteric syndrome; employment and marital status; some sexuality characteristics and some risk factors present or not, that is, they were studied in two ways: present or absent. The patient’s nutritional classification was made using the index of body mass and the presence of some diseases was also determined. With these elements defined, we proceeded with the objectives proposed.

Data Processing

The data were processed manually and using a calculator. The following statistical methods were used: the average menopausal age was calculated and differences in the qualitative variables were found using the chi square test with the Yates correction for the 2x2 tables. The rest is shown in percentages. The data gathered is presented in tables and graphs for easier understanding.

RESULTS

The average age of menopause onset was 47.9 years. The main signs of the climacteric syndrome (Graphic 1) in this group of women were hot flashes (70.6%), sweating (57.3%), anxiety (50% and depression (49%). Most of these patients (85.0%) thought they had to suffer these symptoms.

Table 1 shows some aspects related to sexuality and relationships. It can be observed that 26.9% of perimenopausal women and 42.4% of postmenopausal ones do not have stable partners. This same table shows that lack of privacy predominated, being reported by 49.1% of perimenopausal women and 52.0% of postmenopausal ones. The difference between the two groups was not significant. Next came avoidance of sexual relations, found in 46.2% of the perimenopausal women and 67.2% of the postmenopausal ones. A decreased sexual drive was found in 44.5% of the perimenopausal women as compared to 64.8% of the postmenopausal ones, with a significant difference between both groups. In postmenopausal women, vaginal dryness (68.8%) was the most frequently reported symptom.

The opinion that these women regarding relations with their partners is also shown in Table 1. They were good for 32.0% of the perimenopausal women and for 37.6% of postmenopausal ones. The difference between both groups was not significant. Relations were considered to be bad for 52.6% of perimenopausal women and 52.0% of the postmenopausal group.

Table 1: Some Characteristics of Sexuality

*: p<0,05
Source: Questionnaire

The work status of these women is shown in Graphic 2. An important number of perimenopausal women work - 68.5% - while in the postmenopausal group, 42.4% reported working. This difference is significant. Of these women, 36% of the perimenopausal and 30.1% of the postmenopausal, had problems in their work, mainly because of absences and delays due to caring for grandchildren and sick or older relatives.

Table 2 shows some risk factors that can be observed in this group of women. Among them, lack of physical exercise in 80% of perimenopausal women and 90.4% of the postmenopausal ones stands out, followed by smoking, for 60% of the women in the first group and 54% in the second, and obesity or being overweight, for 48% and 52%, respectively. Another observation was that a large group does not self-examine their breasts (44.5% of the perimenopausal women and 48% of the postmenopausal ones), and 38.8% of perimenopausal women and 40.8% of the postmenopausal ones do not have an updated Pap smear.

Table 2: Risk Factors

Table 3 shows the main complaints of these patients according to their questionnaire responses, including pain in the bones, muscles and joints for 16% of perimenopausal, and 20% of postmenopausal women followed by arterial hypertension for 12.5% of women in the first group and 14.4% in the second.

Table 3: Main Complaints

DISCUSSION

It is evident that these women constitute a group with a very well defined epidemiological profile, in which, as we shall see, health interventions play an essential role, especially when they are analyzed from the point of view of primary health care and the family doctor.

Climacterium is considered a physiological stage, which, nevertheless, is frequently accompanied by symptoms and potential risks that many women consider a real burden. Among these are incapacitating diseases such as osteoporosis, cardiovascular diseases, memory and sexuality disorders, urogenital problems and the symptoms of the stage itself; these and other factors can make the remaining years of a woman’s life miserable and so require actions to improve life quality. Educational intervention is important in this sense and the family doctor is the most suitable person to carry it out.

The climacteric syndrome is very frequent (10) and is found in 2 out of 3 women. It begins at premenopause and declines with time. In our group, hot flashes (70.6%) predominated, followed by sweating (57.3%), anxiety (50.0%), and depression (49.0%). It is difficult to establish the relation existing between the patients’ symptoms and the factors that create predominate symptoms in certain groups. Besides the main factor (estrogen deficit), we must consider the psychological and social characteristics and the environment in which they lived and the one in which they live at present. As we were able to observe from the results, most of them had difficulties in several areas: psychological, sexual, family, labor, etc. For that reason, it is important to keep in mind the WHO concept of health: “a complete state of physical, mental and social welfare and not merely the absence of disease” to understand the importance of caring for these women with a holistic approach towards all the signs they show.

Some authors, for example, Artiles and Manzano, (11) have pointed out that women express symptoms that do not always correspond with the physiological status of the climacteric stage she is going through. Here, it is very important to identify what underlies this request or complaint, which, as we just mentioned, may involve many areas. The clinical expression of the climacteric syndrome is associated with the lifestyle the woman led until the moment her menstruation ceased, as well as her cultural and economic levels, the relations within the couple and her life expectations. (12)The climacteric experience varies from woman to woman, from culture to culture, and still involves an important cultural taboo. (13) These considerations are important when interviewing such patients. The primary care doctor has more possibilities of knowing the environment that surrounds them; hence, the advantage he has and the importance of treating them at this level.

Another important aspect in this stage of life is sexuality. We believe that what we have found concerning the sexuality and relationships of these women is very important for understanding their overall stability. Other authors have already referred to many of these factors. (14)(15)(16) A group of women in our study did not have stable partners, mainly postmenopausal ones. This is an affliction that this group must face and which may lead to melancholia and depression. Let us remember that this was one of the main symptoms mentioned by these women. Sexuality is a wide range of emotional, physical, intellectual, ethical, psychological and social phenomena that shape the life of any individual. (16) Hence, the importance of its study and the repercussion it may have on other areas, mainly in this stage of life. Some authors, like Artiles, (12) suggest that the woman’s sexual behavior should not be modified during this stage and that it is necessary to help these women maintain a full sexuality, since sexual relations reduce tension, make a woman feel more desired, help sleep and provide physical relief for her emotions.

Within the environment, the labor issue is important, as it represents a significant social and economic status for women and the guarantee of a pension. As we saw in the results, a large number of these women work and many have labor problems, like absences and delays, because of having to care for grandchildren and other family members. Here - as in many other respects - the gender issue is present: “it is the grandmother that must care for grandchildren;” “women at this age have to go through these symptoms;” etc. In other words it is the genetic and social pattern, which culturally assigns the symptoms and many behavioral aspects to menopause. Women are not able to identify the gender factor as a deeply felt need and assume the behavior mentioned. They attribute their discomforts to climacterium or menopause. The gender role is, therefore, a substantial aspect to consider in the integral health of the climacteric woman. As Anderson points out, it is a great obstacle in achieving woman’s health. (17)

The general changes in the life of a woman during this stage, instability of life in couple and the sexuality disorders, as well as the changes in social and economic status, among other things, increase the general trend towards depression and loss of emotional stability and integral health. (18) The identification and possible solution of all the conflicts intrinsic to the different problems these patients present will, undoubtedly, contribute to improve their quality of life. This must be a first priority objective for the doctors and the health team that cares for these patients at a primary level.

The results obtained with respect to risk factors are important. Smoking, not exercising and obesity or being overweight were findings in a large number of women, both perimenopausal, as well as postmenopausal, that greatly increase morbidity.

As everyone knows, smoking is a risk factor for several diseases: among them, arterial hypertension and ischemic cardiopathy, disorders that are highly prevalent during climacterium, as has been shown. (19)

The benefits of performing routine, dynamic physical exercises for restoring normal arterial pressure, (20) and also for prevention of osteoporosis, another important disorder at this age, have been pointed out.

The prevalence of hypertension is 50% higher in overweight and obese persons with respect to those having normal weight, (21)(22)(23) thus the importance of insisting on the prevention of this factor.

With respect to cancer morbidity, there are several factors that increase its frequency during climacterium. There is a group of neoplasias, especially those of the breast, endometrium, uterine cervix and ovaries that show maximum frequency of occurrence after 50 years. (24)

In early detection of breast cancer, the self-exam is a very useful tool for early diagnosis and contributes to a better knowledge of the body and, above all, to create a consciousness of the problem and of the importance of the woman’s responsibility for her own health. Coincidentally, the climacteric stage is also the stage of highest breast cancer frequency, mainly between 51 and 60 years of age. (25) The same holds true for the Pap smear, as a key element for an early diagnosis of cervix cancer. In both cases, a group of the women studied do not have these tests done, hence, the importance of education, which is mainly carried out at the primary level.

The results for the main disorders, emphasize the importance of all that we have previously mentioned. The appearance or triggering of some diseases, such as blood hypertension, are in relation to stress (26)(27) and some signs of the climacteric syndrome found in our patients are considered severe expressions, such as anxiety and depression.

Palacios shows that professionals taking care of climacteric and menopausal women must take a holistic medical approach, using primary care criteria and providing them with comprehensive health care not limited to treating certain pathologies and relieving some of the symptoms. They must prevent the development of some diseases and aim at the detection and control of risk factors to help women realize a satisfactory state of health. (28)

With these results, applying the concepts of the risk approach becomes decisive, since it gives a measure of the need for integral health care in climacteric women. Understanding risk or the probability of having future health problems in advance enables adequate and timely prevention or intervention to avoid or modify possible damages. Hence, the importance of selective referral to dispensaries of these women according to their risk factors or pathologies.

Medicine's ideal - prevention - has, in the climacteric process, one of the most fertile fields of practice. As we have seen, and statistics in developed countries demonstrate, the increase in life expectancy, with excellent quality of life, can be achieved simply by modifying the life style, increasing positive habits and eliminating negative ones, regardless of the diagnostic or therapeutic methods used. (29)

We believe, that in our country, we have the need to preserve the life and health standards of Cuban women (30) especially now, since with the increase in life expectancy, an increasing number of them reach menopause and face the disorders caused by the changes occurring at this life stage.

CONCLUSIONS

• The average age for menopause was 47.9 years.
• The most frequent symptoms of the climacteric syndrome were: hot flashes, sweating, anxiety and depression.
• An important group of these women did not have a stable partner, which was higher in postmenopausal women (42.4%).
• Among some of the characteristics of their sexuality: lack of privacy, avoidance of sexual relations and decreased sexual drive predominated in perimenopausal women; while, vaginal dryness, avoidance of sexual relations and decreased sexual drive prevailed in postmenopausal ones.
• The majority of the patients in both groups classified couple relations as bad.
• Many of the women who work (68.5% of the perimenopausal and 42.4% of the postmenopausal ones) experience difficulties in their work, mainly absences and lateness, since they have to take care of grandchildren and other relatives.
• The main risk factors detected were: lack of physical exercise, smoking, and obesity or being overweight, as well as not performing the self-examinations of the breast or obtaining Pap smears.
• Menstrual disturbances and arterial hypertension predominated in perimenopausal women, and bone-muscle-joint pain and arterial hypertension in postmenopausal ones.

REFERENCES

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THE AUTHORS

*Second Degree Specialist in Gynecology and Obstetrics, Playa Teaching Polyclinic. Miguel Lugones, MD was awarded First Prize in the Reproductive Health Competition of the journals MEDICC Review and Revista Cubana de Salud Pública in 2000. Member of the Climacterics and Menopause Section of the Cuban Gynecology and Obstetrics Society and also member of the Child and Adolescent section of said Society; lugones@infomed.sld.cu.

**First Degree Specialist in Gynecology and Obstetrics, Jorge Ruíz Ramírez Polyclinic, Playa

***First Degree Specialist in General Integral Medicine, 26 de Julio Teaching Polyclinic, Playa

APPENDIX 1. Questionnaire For The Study Of Climacterium

We are carrying out a study on the climacteric stage. We need your collaboration. If you accept, we ask you to be as sincere as possible. Thank you.

I. Age:____ Age at onset of menopause (12 months without menstruation)_____

Occupation:_______________________

If you do work, do you have difficulties carrying out your work? If the answer is yes, briefly explain why.

II. Marital status: Stable partner_____ Without stable partner _________

III. a) List the main signs or symptoms you present related to this stage of climacterium and menopause:

b) Do you consider that these symptoms you have mentioned always have to appear at this age? Yes___ No___

IV. a) Are your sexual relations:

Satisfactory? Yes _____ No________

Do you avoid them? Yes ___ No_____

Do you have privacy? Yes ____ No_____

Do you have vaginal dryness? Yes ___ No_____

Has your sexual drive increased? Yes ____ No_____

Has your sexual drive decreased? Yes ___ No_____

b) How would you classify your relations with your partner?

Good_____ Not Bad____ Bad______

If you answer not bad or bad, briefly explain why.

V. Risk factors:

Smoking: Yes _____ No______

Do you systematically perform physical exercise: Yes ___ No____

Weight_______ Height_______ Index of body mass_________

Do you self examine your breasts: Yes ___ No_____

Is your Pap smear updated: Yes _____ No_____

VI. Mention if your suffer from any ailment: