International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 7 Awareness and Perceptions Towards Menopause Among Saudi Women Mufareh Asiri 1 , Majed Al shahrani 2 , Hajer Alamer 3 , Shoug Alkhursan 3 , Huda Alhashem 3 , Enas Alshashaa 3 , Manal Alamri 4 ,Fatima Alshehri 5 1 Armed forces hospital southern region (AFHSR), OB/GYN department (KSA) 2 Najran university , OB/GYN department (KSA). 3 Medical interns , King Khalid University (KSA) 4 North west armed forces hospital, Tabuk (KSA). 5 Armed forces hospital southern region (AFHSR), OB/GYN department (KSA) Abstract: Background : Menopause is an important period of women life .it is a normal physiological process, defined as the permanent cessation of menses for 12 months or more. Our study assess the awareness and perception of Saudi women aged from 30 to 65 years towards menopause and to Address the health needs of women to improve the quality of life of menopausal Saudi women. Methods: Cross sectional study by using survey distributed electronically through kingdom of Saudi Arabia for Saudi women between ages of 30-65 years old. Results: The number of participant were total of 738 women, 130 women were menopause already. Most of participant were from southern region (67%). Study shows that 51-55 years old is the average age of menopause. Our participant (41.9%) they choose the answer of "inability of ovary to produce egg "as definition of menopause while (17.6 %) choose "cessation of mensuration for more than 1 year), most of women (31.9 %) they though that psychological symptoms will be more prominent with significant p value (0.003), while among menopause group they choose hot flush as the most prominent symptoms (38.5%). About 70% of our sample they mention that they don't have enough background about menopause. Conclusion: Heath education with proper medical advices should be a part of primary health clinics projects. Media and menopause groups play important role to help health providers Keywords: menopause, perception, Saudi women Corresponding author: Mufareh Asiri, Email: dr.mufareh@yahoo.com, 00966553725252 1. INTRODUCTION Menopause is an important period of women life .it is a normal physiological process, defined as the permanent cessation of menses for 12 months or more (1, 2). According to the World Health Organization (WHO) classification, premenopausal women are those who have experienced regular menstrual bleeding within the last 12 months, perimenopausal women are defined as those women who have experienced irregular menses within the last 12 months or the absence of menstrual bleeding for more than 3 months but less than 12 months, and postmenopausal women are those who have not experienced menstrual bleeding for 12 months or more. Women with iatrogenic menopause are those for whom periods have stopped as a result of medical or surgical intervention, for example, due to chemotherapy or radiation of ovaries, hysterectomy or oophorectomy, or both. The age at natural menopause is between 45 years and 50 years. Early menopause is defined as menopause occurring before the age of 45 years, while premature menopause occurs before the age of 40 years. (1) In Saudi Arabia female represents (49.06%). Saudi female in age of 65 years old and more represent (51.1%). (3) One of the main issue is lack of specialized menopause clinics or menopause groups in most of the area. Also most of women are afraid of hormonal replacement therapy due to traditional believe. According to vision of 2030, the expectant age will prolong to more than 75 years old. So according to that , the heath provider must work to establish more specialized clinic to enhance the health of women in this age and to reduce the comorbidities and the cost related to it . In our study we tried to assess the awareness and perception of Saudi women aged from 30 to 65 years towards menopause and to Address the health needs of women to improve the quality of life of menopausal Saudi women. 2. METHOD: It is across sectional study approved by ethical committee of (Najran University), kingdom of Saudi Arabia .The survey was carried out among pre-menopausal and post-menopausal Saudi women. By using modified Menopause Rating Scale (MRS) related questionnaire as a basis for assessing menopausal symptoms in this study, this is a selfadministered instrument which has been widely used and validated and have been used in many clinical and epidemiological studies, and in research on the etiology of menopausal symptoms to assess the severity of menopausal symptoms. (9) An electronic Arabic questionnaire from age International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 8 of 30 years old to age of 65 years old .it was disturbed all over the kingdom of Saudi Arabia through " face book , twitter, whats app and telegram " through the period of October 2017 till December 2107 .Inclusion criteria: Saudi women aged 30-65 years. Exclusion criteria: Non Saudi women, women aged less than 30 years and more than 65 years All the participant fill it up and send it back to us. Answer of all question was mandatory, so no questions was escaped. After filling the questionnaire, the participant will submitted it back online again. The questionnaire was contains 3 parts. First part contains 10 questions including (age, area of residency, marital status, if she has children or no, education level, if she is working or no, age of first menstruation, if she is menopause or not yet Her background about age of menopause and definition). The second part contain 22 questions for menopause women including ( age of last menstrual period , the most prominent symptom made her think that she is menopause , the pattern of her period before stopping , if there is medical or surgical intervention made her menopause earlier , if menopause affect her regular activity , affect relation with husband , children or sexual relationship , did she seek medical advice , if she heard about menopause group , if she did medical test or checkup , if she has medical disorder ,if she heard or used hormonal replacement therapy , if she is doing exercise or following healthy diet and what kind of diet she thought it is appropriate , what kind of service they need from medical staff and how is she feeling in general in this age ). The third part contain 20 question for those who didn't reach the age of menopause yet. It is the same questions of section two. To measure their awareness about age of menopause and what they will do when they reach this age. Data were collected, coded and fed to statistical software IBM SPSS version 21. All statistical analysis was done using two tailed tests and alpha error of 0.05. P value less than or equal to 0.05 was considered to be statistically significant. Descriptive statistics was done by showing frequencies and percentages for categorical variables. Chisquare or exact tests were used to test for association between menopausal status and sample attributes and with also menopause awareness and perception. 3. RESULTS: Table (1): Socio-demographic characteristics of Saudi females aging 30 to 65 years according to their menopausal status, Saudi Arabia, 2017 Socio-demographic characteristics Are you menopause? P Yes No No % No % Age in years 30-35 7 5.4% 235 38.7% 0.001* 36-40 26 20.0% 146 24.0% 41-45 13 10.0% 122 20.1% 46-50 32 24.6% 88 14.5% 51-60 52 40.0% 17 2.8% Marital status Single 5 3.8% 54 8.9% 0.063 Married 117 90.0% 523 86.0% Divorced 3 2.3% 22 3.6% Widow 5 3.8% 9 1.5% Children Yes 114 87.7% 514 92.8% 0.545 No 16 12.3% 94 15.4% Region of residence Southern region 80 61.5% 413 67.9% 0.552 Northern region 1 .8% 10 1.6% Eastern region 16 12.3% 63 10.4% Western region 10 7.7% 38 6.3% Central region 23 17.7% 84 13.8% Education level Primary 33 25.4% 29 4.8% 0.001* Intermediate 6 4.6% 33 5.4% Secondary 47 36.2% 144 23.7% International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 9 University / higher 44 33.8% 402 66.1% Work Private section 2 1.5% 26 4.3% 0.124 Governmental section 49 37.7% 262 43.1% Not working 79 60.8% 320 52.6% Age at first menstruation Less than 10 years 13 10.0% 13 2.1% 0.001* 10-12 40 30.8% 217 35.7% 13-15 74 56.9% 343 56.4% 16-17 3 2.3% 35 5.8% * P < 0.05 (significant) Table (2): Menopause awareness among Saudi females aging 30 to 65 years in relation to their menopausal status, Saudi Arabia, 2017 Menopause awareness items Are you menopause? P Yes No No % No % Menopause symptoms you have/ will have Hot flushes 50 38.5% 143 23.5% 0.003* Psychological symptoms 30 23.1% 194 31.9% Vaginal dryness 13 10.0% 102 16.8% Vaginal bleeding 23 17.7% 120 19.7% Sexual problems 14 10.8% 49 8.1% Menstruation stopped Suddenly stopped 32 24.6% 31 5.1% 0.001* Gradually stopped 52 40.0% 268 44.1% Irregular bleeding then stopped 40 30.8% 228 37.5% Couldn't remember 6 4.6% 81 13.3% Menopause affect your regular activity Yes 36 27.7% 35 5.8% 0.001* No 94 72.3% 511 84.0% Don't know 0 0.0% 62 10.2% Menopause affect your relationship with your husband Yes 38 29.2% 107 17.6% 0.001* No 87 66.9% 351 57.7% Don't know 5 3.8% 150 24.7% Menopause affect your relationship with your children Yes 8 5.15% 52 8.6% 0.001* No 109 83.8% 459 75.5% Don't know 13 10.0% 97 16.0% Menopause affect your sexual relationship Yes 23 17.7% 146 24.0% 0.001* No 101 77.7% 283 46.5% Don't know 6 4.6% 179 29.4% Have any idea about the menopause women groups Yes 20 15.4% 152 25.0% 0.019* No 110 84.6% 456 75.0% Medical checkup should done Cardiac check up 2 1.5% 45 7.4% 0.001* Cholesterol check up 10 7.7% 11 1.8% Blood pressure check up 8 6.2% 33 5.4% International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 10 Blood sugar check up 43 33.1% 19 3.1% Bone mineral density 16 12.3% 198 32.6% Pap smear 5 3.8% 222 36.5% Mammogram 14 10.8% 0 0.0% None of the above 32 24.6% 80 13.2% Heard about Hormone Replacement Therapy Yes 35 26.9% 139 22.9% 0.322 No 95 73.1% 469 77.1% Food suitable for menopause women Meat and chicken 2 1.5% 14 2.3% 0.143 Fruits and vegetables 95 73.1% 448 73.7% Dairy products 8 6.2% 66 10.9% Don't know 25 19.2% 80 13.2% * P < 0.05 (significant) Continued... Menopause awareness items, continued Are you menopause? P Yes No No % No % Age of menopause (years) 45-50 54 41.5% 148 24.3% 0.001* 51-55 63 48.5% 348 57.2% 56-60 13 10.0% 98 16.1% Above 60 years 0 0.0% 14 2.3% Menopause is: The end of menstruation for 1 year 21 16.2% 108 17.8% 0.026* Unable to get pregnant 10 7.7% 101 16.6% Unable of ovary to produce eggs 67 51.5% 243 40.0% Don't know 32 24.6% 156 25.7% You should seek medical advice Yes 21 16.2% 480 78.9% 0.001* No 107 82.3% 22 3.6% Not important 2 1.5% 106 17.4% * P < 0.05 (significant) International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 11 Table (3): Menopause perception among Saudi females aging 30 to 65 years in relation to their menopausal status, Saudi Arabia, 2017 Menopause perception items Are you menopause? P Yes No No % No % At age of menopause how do you feel your life Getting better 36 27.7% 103 16.9% 0.001* Getting worse 18 13.8% 98 16.1% No change 76 58.5% 185 30.4% I don't know 0 0.0% 222 36.5% Doing exercise Yes 48 36.9% 590 97.0% 0.001* No 82 63.1% 18 3.0% Following health diet Yes 38 29.2% 580 95.4% 0.001* No 92 70.8% 28 4.6% In general ,How you are feeling Happiness 28 21.5% 63 10.4% 0.001* Hopelessness 1 .8% 34 5.6% Less beauty 8 6.2% 66 10.9% More fatigue 32 24.6% 104 17.1% Fear of future 9 6.9% 152 25.0% No changes 52 40.0% 189 31.1% Needs from medical staff More education and awareness 45 34.6% 210 34.5% 0.939 Specialized clinics 27 20.8% 134 22.0% Facility to home care 9 6.9% 34 5.6% Psychological support 49 37.7% 230 37.8% * P < 0.05 (significant) International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 12 Table (4): Menopause related data among sample of Saudi females aging 30 to 65 years in menopausal status, Saudi Arabia, 2017 Menopause related data No % Age when you get your last menstrual period 30-352 29 22.3% 36-40 11 8.5% 41-45 12 9.2% 46-50 47 36.2% 51-55 25 19.2% 56-60 6 4.6% Received any medical or surgical treatment that made your menopause earlier Yes 43 33.1% No 87 66.9% If yes, mention Hormonal treatment 17 39.5% Chemotherapy or radiotherapy 4 9.3% Surgical (hysterectomy, ovaryectomy) 22 51.2% The number of participant were total of 738 women, 130 women were menopause already. Most of participant were from southern region (67%). The married women represent about (82.7%). More than 50% of participant were from high education (university level), and 54% are not working. about 56 % go their menarche at age between 10 and 13 years old . Regarding their back ground about age of menopause ,(55.8%) choose the answer of age between 51-55 years old , and (41.9%) they choose the answer of " inability of ovary to produce egg " as definition of menopause while (17.6 %) choose " cessation of mensuration for more than 1 year ) . (Table 1). Regarding the perception of the most prominent menopausal symptoms, most of women (31.9 %) they though that psychological symptoms will be more prominent with significant p value (0.003), while among menopause group they choose hot flush as the most prominent symptoms (38.5%). regarding the pattern of stop of mensuration both group choose that gradual stop of menstruation is the most common pattern with significant p value (0.001). Regarding the perception if the menopause affect the regular activity, relation with husband or children or effect on sexual relationship, most of participant choose the answer (NO) with significant p value (0.001). Most of participant didn't heard about menopause support group (p value (0.019)). Among the group of menopause, (33.1%) choose that blood sugar check up is the most important test to be done in this age while (24.6%) of them didn't do any medical checkup. Among the young women they though that the pap smear and bone mineral density are the most important test to be done at age of menopause. Regarding the hormonal replacement hormone more than 70% of both group didn't heard about it before. Regarding the food suitable in menopause age (73%) of both group choose that fruit and vegetable are most important food in this age, most of menopause group are not following healthy diet and not doing exercise . The young women are believing in healthy International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 13 diet and doing exercise in menopause age p value (0.001). (Table 2, 3) One of the interesting that (82.3%) of menopause group didn't seek medical advice in this age while in other group (78.9%) are believing in the importance of seeking medical advice in this age, P value (0.001). (Table 2) In general both group they think that no emotional changes will be significant in menopause age with significant p value (0.001). Both groups agreed that the psychological support from medical staff is the most important need in this age but the p value was not significant p value (0.939). Unfortunately 70% of our sample they mention that they don't have enough background about menopause. 4. DISSUASION: According to the statistics of Saudi Arabia 2017, Saudi population (20,408,362), female represents (49.06%). The same statistics shows that Saudi female more than 65 years old represent (51.1%). (3) The Perception and concepts of illness and health are based on background, thoughts and level of education. The health services in Saudi Arabia are free and supported by government. Most of female in Saudi Arabia had their menarche between the ages of (13-15) years old which is comparable to other countries. The average age of menarche is about 12.5 years in the United States,(4) 12.72 in Canada,(5) and 12.9 in the UK.(6) A study of girls in Istanbul, Turkey, found the median age at menarche to be 12.74 years.(7) Most of women in our study thoughts that age of menopause is between 51 -55 years, which is consistent with the picture emerging from previous studies from Saudi Arabia and the gulf region. William and colleagues 2003 shows that the median age of menopause in Saudi Arabia is 50 years. (8) The perception of most women shows that psychological symptoms is more than somatic symptoms. In other local study done in (Abha, Saudi Arabia) shows that somatic symptoms are more followed by psychological symptoms. (9) Nisar N (2009), reported that the scores of psychological domain were significantly high in menopause transition women P < 0.003) (10) In United States it is estimated that 20% have depression at some point during menopause period. (11) Less women in Saudi Arabia they though that sexual symptoms will be prominent during menopause age. Indeed most of women they are not reporting such problem to their health providers due to some social barriers. Actually the exact incidence and etiology are unknown. Many factors are playing role , it includes decreased interest or desire to initiate activity, as well as decreased arousal or ability to achieve an orgasm during sexual intercourse . It could be also due to psychological problems such as depression or anxiety disorders. Our women they thought that pattern of mensuration will stop gradually before the last mensuration period. In one study the authors found that serial irregularity of bleeding pattern was a strong predictor of onset of menopause.(12) One of the interesting in our study shows that menopause will not affect regular activity among Saudi women. One study shows that not all women who report menopausal symptoms are affected by them. (13) The Study of Women's Health across the Nation (SWAN) measured health-related quality of life of approximately 3,000 women and found that many of the symptoms associated with menopause, were also associated with lower quality of life. (14, 15) In other local study noticed moderately poor quality of life due to menopausal Symptoms observed among menopause group. (9) The perception of Saudi women in our study that menopause will not affect relation with husband or children. Worldwide, the prevalence of sexual dysfunction in postmenopausal women ranging from 68% to 86.5 %.)(16) The Global Study of Sexual Attitudes and Behaviors (GSSAB), which included 13,882 women aged 40 to 80 years, reported 26% to 48% of women had a lack of interest in sex, and 18% to 41% of women had difficulty reaching orgasm; these were the most common female sexual dysfunctions (FSD) across world regions. Furthermore, in this study, sexual dysfunction was demonstrated to significantly impact women's self-esteem and quality of life, and cause emotional distress, leading to relationship problems. (16). Our study shows that most of women in Saudi Arabia don't have any idea about menopause supportive groups either because it is not exist or because no social awareness among women about such groups. Heath service in Saudi Arabia is free and developing quickly but the presence of specialized menopause clinics is not widely spread, While our study shows that most of young women believing in seeking medical advice when they will reach the age of menopause. Due to that most of women are not aware about the importance of medical checkup that they must do in a routine basis. Based on that most of them didn't heard about hormonal replacement therapy. In our community the trend toward improvement of heath in general is increasing. The women are believing to follow healthy diet and do regular exercise at age of menopause which can maintain their health and improve the symptoms of menopause. In one study measure the physical activity among Saudi women shows that high level of inactivity among Saudi females in reference to the international recommendation. (17) Local study done on 2007 shows the prevalence of physical inactivity among Saudis adults is relatively high. (18) International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 14 In this study most of women they though that age of menopause is physiological changes and no fear of future or sadness feeling will be associated. This could be explained by the strong family relationship and support among Arab population in general. Same finding been noticed among Bahraini women (2008). (19) Psychological changes play important role during menopause. Psychological symptoms increase during menopause due to many factors like loss of fertility or unable to do regular activity as before. Our study shows that most of women need more psychological support from medical staff. Our study shows that 70% of women don't have enough background about menopause. 5. CONCLUSION: Menopause is important physiological period of women life. More specialized clinics should be available. Heath education with proper medical advices should be a part of primary health clinics projects. Media and menopause groups play important role to help health providers. REFERENCES : 1. World Health Organization . Research on Menopause in the 1990s: Report of WHO Scientific Group. Geneva: World Health Organization; 1996. (WHO Technical Report Series 866). 2. Solues MR, Sherman S, Parrott E, Rebar R, Santoro N. Executive summary, stages of reproductive aging workshop (STRAW) Fertil Steril. 2001;8:874–878. 3. www.stats.gov.sa 4. Anderson SE, Dallal GE, Must A (April 2003). "Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart". Pediatrics. 111 (4 Pt 1): 844–50. doi:10.1542/peds.111.4.844. PMID 12671122. 5. Al-Sahab B, Ardern CI, Hamadeh MJ, Tamim H (November 2010). "Age at menarche in Canada: results from the National Longitudinal Survey of Children & Youth". BMC Public Health. 10: 736. doi:10.1186/1471-2458-10-736. PMC 3001737 Freely accessible. PMID 21110899. 6. Hamilton-Fairley, Diana (2004). Obstetrics and Gynaecology (PDF) (2nd ed.). Blackwell. p. 29. ISBN 1-4051-2066-5. Retrieved 2013-11-09. 7. Atay, Z.; Turan, S.; Guran, T.; Furman, A.; Bereket, A (2011-06-13). "Puberty and Influencing Factors in Schoolgirls Living in Istanbul: End of the Secular Trend?". Pediatrics. 128 (1): e40–5. doi:10.1542/peds.2010-2267. PMID 21669888. 8. The frequency distribution of age at natural menopause among Saudi Arabian women William Greer *, Amy L. Sandridge, Rona S. Chehabeddine Maturitas 46 (2003) 263 /272) 9. The prevalence of symptoms experienced during menopause, influence of Socio-demographic variables on symptoms and quality of life among women at Abha, Saudi Arabia. Hassan M. Al-Musa, Biomedical Research 2017 10. Nisar N, Sohoo NA. Frequency of menopausal symptoms and their impact on the quality of life of women: a hospital based survey. J Pak Med Assoc 2009; 59: 752-756 11. Soares CN. New York, Arlington, VA: American Psychiatric Publishing; 2004. Perimenopause-related Mood Disturbance: An Update on Risk Factors and Novel Treatment Strategies Available. In: Meeting Program and Abstracts. Psychopharmacology and Reproductive Transitions Symposium. American Psychiatric Association 157th Annual Meeting; May 1.6, 2004; pp. 51–61.) 12. Timing of Menopause and Patterns of Menstrual Bleeding M. Weinstein T. Gorrindo A. Riley J. Mormino J. Niedfeldt B. Singer G. Rodríguez J. Simon S. Pincus American Journal of Epidemiology, Volume 158, Issue 8, 15 October 2003, Pages 782–791. 13. Feldman BM. Voda A. Gronseth E. The prevalence of hot flash and associated variables among perimenopausal women. Res Nurs Health. 1985;8:261– 268 14. Avis NE. Ory M. Matthews KA, et al. Health-related quality of life in a multiethnic sample of middleaged women: Study of Women's Health Across the Nation (SWAN) Med Care. 2003;41:1262–1276 15. Avis NE. Colvin A. Bromberger JT, et al. Change in health-related quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: Study of Women's Health Across the Nation (SWAN) menopause. 2009;16:860–869.) 16. Addis IB, Van Den Eeden SK, Wassel-Fyr CL, et al. Sexual activity and function in middle-aged and older women. Obstet Gynecol. 2006;107:755–764 17. Einas S. Al-Eisa and Hana . Al-Sobayel Physical Activity and Health Beliefs among Saudi Women, Journal of Nutrition and Metabolism Volume 2012 (2012) 18. Hazzaa M Al-Hazzaa Health-enhancing physical activity among Saudi adults using the International International Journal of Academic Health and Medical Research (IJAHMR) ISSN: 2000-007X Vol. 2 Issue 2, February – 2018, Pages: 7-15 www.ijeais.org/ijahmr 15 Physical Activity Questionnaire (IPAQ), ,Public Health Nutrition,2006 19. Ghufran Ahmed Jassim ∗, Qasim Al-Shboul, Attitudes of Bahraini women towards the menopause: Implications for health care policy, European menopause journal (2008) 358–