Quality of Life Among Post-Menopausal Women Residing in Selected Ward of Itahari Sub-Metropolitan City, Nepal

: Background: Menopause is a critical period in a woman’s life that not only marks the end of reproductive ability but is also associated with multiple vasomotor, psychological, physical and sexual complaints. So, the study of Quality of Life in the post-menopause has become an essential component in clinical practices. The objective of this research was to assess the quality of life among post-menopausal women. Materials and Methods: A descriptive cross-sectional study was conducted among 102 women of Itahari Sub-Metropolitan city. Probability sampling technique was used to select the ward and non-probability purposive sampling technique was used for the selection of sample. Data was collected through face-to-face interview using a structured Menopause-Specific Quality of Life (MENQOL) questionnaire. Descriptive statistics (frequency, percentage, median and interquartile range) and (Man Whitney U test) for inferential statistics were applied using SPSS Version 25 for data analysis. Result: The study showed that the most common symptom reported by the respondents was feeling tired (98.04%) and the least frequent symptom was increase in facial hair (11.76%). The median scores and interquartile range of MENQOL for vasomotor, psychosocial, physical and sexual domains were 4(3,4), 12.50(10,15), 31(28,38) and 5(3,6) respectively. The significant difference was seen in vasomotor domain with marital status and occupation, psychosocial domain with age and marital status and sexual domain with occupation respectively. Conclusion: In this study, the most frequent reported symptom was feeling tired and the most affected domain was physical domain. The vasomotor domain has statistically significant difference with marital status and occupation, psychosocial domain has statistically significant difference with age and marital status and sexual domain has significant difference with occupation respectively. Hence, effective awareness and education programme regarding the symptoms and ways to minimize those symptoms should be planned and provided both at individual and community levels.


Background of the Study
Menopause refers to the permanent cessation of menstruation resulting from the loss of ovarian follicular activity due to aging which occurs after 12 consecutive months of amenorrhea and postmenopause is the period following menopause (Koirala, Thapa, & Shrestha, 2020). According to World Health Organization (WHO), natural menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity (Ambikairajah, Walsh & Cherbuin, 2022). It is a physiological event in the women's life and is caused by aging of ovaries which leads to decline in the production of ovarian Gonadotrophins Estrogen and Progesterone (Nisar, & Sohoo, 2010). The age at which natural menopause occurs is between the ages of 45 and 55 years for women worldwide (Ali et al., 2014). However, cessation of menstruation can occur at any period of life because of ovarian failure . Menopause is a critical period in a woman's life that not only marks the end of reproductive ability but is also associated with multiple physical, vasomotor, psychological, and sexual complaints (AlDughaither, AlMutairy, & AlAteeq, 2015).
Even though, menopause is a universal reproductive phenomenon, it can be perceived as an unpleasant experience as it is associated with unavoidable manifestation of aging process in women . Menopausal symptoms can include hot or cold flushes, night sweats, joint pain, vaginal dryness, decreased sexual desire, insomnia and emotional changes (Ghimire et al., 2015). Studies find that most women experience at least one or more of these symptoms as they transition through the postmenopausal stage of life (Mohamed, Lamadah, & Al Zamel, 2014). The duration, severity, and impact of these symptoms vary from person to person, and population to population. Some women have severe symptoms that profoundly affect their personal and social functioning, and quality of life (QOL) (Abedzadeh Kalarhoudi et al., 2011).
Globally, 20% of women have no noticeable changes, other than their periods stopping. However, 70% consider menopausal changes a mild to moderate nuisance. About 10% find their symptoms severely distressing (Prajapati, Shrestha, & Sanjel, 2018). Asian women, showed body or joint aches/pains as the most prevalent symptom, which ranged from 76% in Korean women to 96% in Vietnamese women (G K, & Arounassalame, 2013). The study in Sri Lanka revealed that the most prevalent menopausal symptoms were joint and muscular discomfort (74.7%), physical and mental exhaustion (53.9%), and hot flushes (39.1%) (Prajapati, Shrestha, & Sanjel, 2018). In Pakistan, 66.3% of women reported hot flushes, almost similar results were reported from Sydney and Holland (Nisar & Sohoo, 2009). In a study which was done in UAE, 69% of the women reported physical symptoms, 58.7% reported psychosocial symptoms, 40% reported vasomotor symptoms and 37.9% reported sexual symptoms (G K, & Arounassalame, 2013). A study in US showed that menopausal women suffered from hot flashes affected work (46.0%), social activities (44.4%), leisure activities (47.6%), sleep (82.0%), mood (68.6%), concentration (69.0%), sexual activity (40.9%), total energy level (63.3%) and overall quality of life (69.3%). A study in India revealed that the most common symptom within study subjects were low back ache (79%) and muscle-joint pain (77.2%) (Prajapati, Shrestha, & Sanjel, 2018). In Nepal, the most common symptoms reported were from physical domain, present in all of the participants while the vasomotor symptoms were present in 47.5% of respondents with sweating and hot flushes as common symptoms (Rajbhandari et al., 2017).
According to WHO, Quality of life (QoL) is an individual's perception of their position in life in the context of culture and values system in which they live and in relation to their goal expectations, standards and concerns (Anon, 2022). The study of QoL in the post menopause has become an essential component in clinical practices (Nisar & Sohoo, 2009). The effect of menopausal transition on women's lives is complex and includes changes in physical health, psychosomatic domains, and personal life. Health-related quality of life may be severely compromised in women with vasomotor symptoms. Up to 40% of women in Sweden experience vasomotor symptoms until the age of 64 years (Mohamed, Lamadah, & Al Zamel, 2014). Quality of life comprises of four domains including vasomotor, psychosocial, physical and sexual domains which are experienced by 80% of the menopausal women (Prajapati, Shrestha & Sanjel, 2018). More than 80% of women experience physical or psychological symptoms in the year approaching menopause with various distress and distribution in their lives, leading to decrease in quality of life (Nisar & Sohoo, 2009).

Statement of the Problem
Menopause signifies a normal aging process that brings transition in a women's life from the reproductive to nonreproductive phase. It is a crucial turning point of a woman's life and is naturally designed as an aspect of the aging process (Ghimire et al., 2015). So, this is the entry point for old age and it reduces the quality of life of women, and so women are not ready to accept these manageable changes at once (Ali et al., 2014). Few studies, however, have examined the interrelated nature of symptoms associated with the post-menopausal period and the effects of those symptom groups on quality of life (Mohamed, Lamadah & Al Zamel, 2014). This transition is normally not sudden or abrupt, it tends to occur over a period of years, and it is a natural consequence of aging (Ali et al., 2014). However, for some women, the accompanying signs and effects that can occur during the postmenopause period can significantly disrupt their daily activities and their sense of well-being. The vital component of independence in later life is by maintaining good physical functioning with age. Identifying characteristics associated with poor physical functioning could contribute to prevention and management strategies that will help older women to maintain their independence and also therefore their quality of life. Health-care providers play a more visible and instrumental role in continuously assessing post-menopausal women's needs as well as to implement appropriate health educational programs and to develop a new way to meet their demands (Prajapati, Shrestha & Sanjel, 2018). Thus, it is important to assess the quality of life among post-menopausal women.

Significance of the Study
This study might provide baseline information about the quality of life among post-menopausal women. The results obtained in this study could be used by other researchers for more advanced research study as well as it might be helpful for developing awareness program thereby improving quality of life among postmenopausal women.

General objective
To assess the quality of life among postmenopausal women residing in selected ward of Itahari Sub-Metropolitan city.

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To identify the menopause related symptoms • To assess the quality of life among postmenopausal women in different domain • To compare the difference in quality of life domains among post-menopausal women with selected demographic variables.

Variables
Dependent variable: Quality of life among post-menopausal women.
Independent variables: Socio demographic variables (Age, Religion, Ethnicity, Marital status, Type of family, Monthly family income, Educational status, Occupation, Co-morbid diseases, Age at menopause, Duration since menopause).

Conceptual Framework
See Figure 1.

Research Design
A descriptive cross-sectional study design was conducted to assess the quality of life among post-menopausal women.

Research Setting with Justification
This study was carried out in ward no.9 of Itahari Sub-metropolitan city. This setting was chosen on the basis of adequacy of sample.

Study Population
All the post-menopausal women of 45-75 years of age residing in ward no. 9 of Itahari sub-Metropolitan city were chosen as study population.

Sample
All the post-menopausal women of 45-75 years of age residing in ward no. 9 of Itahari submetropolitan city meeting the eligibility criteria were selected as sample.

Sample Size
For the calculation of sample size, the study considers 95% confidence interval and 90% power in community setting to estimate sample size. Thus, the required sample size (n) was 92+ 9.2= 101.2 = 102.

Sampling Technique
Probability sampling technique (simple random lottery method without replacement) was used to select the ward and non-probability purposive sampling technique was used for the sample.

Eligibility criteria
Inclusion criteria: All the post-menopausal women of 45-75 years of age.
Exclusion criteria: Post-menopausal women who had had hysterectomy. Those who were not willing to participate during the data collection. Those women who could not hear or speak.

Data Collection Technique and Instrumentation
Structured questionnaire was used for demographic variables and Menopause Specific Quality of Life (MENQOL) questionnaire was used to assess the quality of life. Interview technique was adopted for data collection.
The tool consists of 2 sections: Section A: Questionnaire related to sociodemographic variables.
Section B: Menopause specific quality of life questionnaire to identify the quality of life among post-menopausal women. Section A: It includes age, ethnicity, religion, marital status, type of family, educational status, occupation, monthly family income, co-morbid diseases, age at menopause, duration since menopause.

Section B:
The MENQOL standard questionnaire tool designed by Hilditch JR, Lewis J in 1996 was used to identify the quality of life among post-menopausal women. It consists of 29 items related to vasomotor (Q1-3= 3), psychosocial (Q4-10= 7), physical (Q11-26= 19) and sexual domain (Q27-29= 3). The systematic scoring for each of the four domains of MENQOL is identical.

Validity and Reliability
Validity: The content validity of the instrument was established by reviewing the literature and consulting the research guide, subject experts, and research advisor's suggestions.
The research instruments were translated into Nepali version with the help of Nepali language experts.
Reliability: Pretesting was done among 10% of total sample with similar characteristics in same setting which were excluded at the time of data collection. The Cronbach's alpha value was 0.84 which was reliable.

Ethical Considerations
The proposed study was conducted after the approval of Institutional review committee (IRC) of the Nobel Medical College Teaching Hospital. Formal Permission was obtained from selected ward office of Itahari Sub-Metropolitan City. The purpose of the study and data collection process was explained to each respondent before data collection. Informed written and verbal consent were obtained from each respondent. Confidentiality was maintained by emphasizing that the information provided would not be disclosed to anyone and would be used for research purpose only.

Data Analysis Procedure
Collected data was re-checked and coded then entered in Microsoft Excel 2010 at pre-prepared master chart. For statistical analysis, it was converted into SPSS (statistical package for social science) version 25.
For descriptive statistics, frequency, percentage, median and interquartile range was calculated along with appropriate tabular presentation was made.
For inferential statistics, Man Whitney test was used to compare the difference in quality of life domains among post-menopausal women with selected demographic variables. P value <0.05 was considered as significant.      1c shows that, two third (66.7%) of the respondents were not having Co-morbid diseases. Among the respondents who were having co-morbid diseases, few (10.8%) of respondents had hypertension. Similarly, more than half (64.7%) of the respondents had menopause at the age of less than and equals to fifty-five years and majority (78.4%) of the respondents had duration of menopause for less than and equals to ten years.    Table 3 illustrates that majority (98.04%) of the respondents were feeling tired or worn out whereas few (11.76%) of the respondents had increased facial hair.      Table 6 illustrates the comparison of difference in quality of life domains with selected sociodemographic variables. There was significant difference between vasomotor domain with marital status with p-value 0.003 in which the median score for others is higher than married women i.e 4 and 3. Similarly, there was significant difference between vasomotor domain with occupation with p-value 0.000 in which median score for homemaker is more than others i.e 4 and 3. likewise, there was significant difference between psychosocial domain with age (p-value 0.032) in which median score for less than and equals to 55 years is more than the age group of more than 55 years i.e 15.50 and 12. Furthermore, it shows that the median score for others is higher than married women i.e 16 and 11 for psychosocial domain. This finding is statistically significant with pvalue 0.000. Likewise, sexual domain has significant difference with occupation (p-value 0.001) in which the median score for homemaker is higher than others i.e 5 and 3. However, there was no any significant difference between physical domain with any variables.

Discussion
The findings of the present study are discussed under the following objectives:

Socio-Demographic Variables
Out of 102 respondents residing in ward no. 9 0f Itahari sub-metropolitan city, the demographic patterns of respondents were age, ethnicity, religion, marital status, type of family, educational status, occupation, monthly family income, co-morbid diseases, age at menopause and duration since menopause.
In this study, more than half (55.9%) of the respondents were in age between 55-65 years while just under a third (30.4%) of the respondents were in age between 66-75 years and less than one fifth (13.7%) of the respondents falls under the age group of 45-55 years. Similarly, most (93.2%) of the respondents were from Hindu religion, few (3.9%) of the respondents were from Buddhist religion, while only (2.9%) of the respondents were from Islam religion. Regarding ethnicity, majority (75.5%) of the respondents were from Brahmin/Chettri ethnic group, least (9.8%) of the respondents were from Janajati ethnic group, while only (4.9%) of the respondents were from Madhesi ethnic group and only (9.8%) of the respondents were from Dalit ethnic group. In relation to the educational status, majority (82.4%) of the respondents can read and write and just below one fifth (17.6%) of the respondents can't read and write. Among the respondents who can read and write, just over a third (36.4%) had completed their education up to secondary level, while one third (33.3%) of the respondents had completed their education up to basic level, whereas few (9.8%) had informal level of education, while only (2.9%) had completed their education up to university level.
Similarly, in relation to the marital status of the respondents, just above two third (69.6%) were married, just above one fifth (21.6%) were widow and only (6.9%) were divorced and only (1.9%) of the respondents were separated. Regarding type of family, majority (72.5%) of the respondents had joint family. Whereas, just above one fourth (27.5%) had nuclear family.
Regarding the monthly income of the family, less than half (47.1%) of the respondents' family income was 15000-30000 while just below one third (32.3%) of the respondents' family income was >30000. Likewise, one fifth (20.6%) of the respondents' family income was <15000 per month. Similarly, majority (81.4%) of the respondents were homemakers, while less than a fifth (16.7%) of the respondents were involved in business, only (1.9%) were involved in services (government/private) and daily wages.
Regarding the co-morbid disease of the respondents, two third (66.7%) of the respondents were not having co-morbid diseases whereas, one third (33.3%) of the respondents were having co-morbid diseases. Among them, few (10.8%) of respondents had hypertension. Similarly, few (8.8%) of the respondents had DM+HTN. Likewise, only (7.8%) had DM and only (5.9%) had thyroid disorder. In relation to menstrual history, Majority (64.7%) of the respondents had menopause at normal age i.e ≤55 years and just above one third (35.3%) had menopause at the age of more than 55 years. Majority (78.4%) had duration of menopause for less than and equals to ten years. Similarly, just above one fifth (21.6%) had duration of menopause more than 10 years.

Related Symptoms of MENQOL
The present study shows that the most common vasomotor symptoms were sweating (46.08%) followed by night sweats (18.63%) and hot flushes (12.75%). The above findings is supported by the study conducted by Thapa P, Thebe P on Quality of life among postmenopausal women in rural area, Nepal from July to November 2020 among 215 postmenopausal women which revealed that sweating as a major symptom of vasomotor domain (Yerra et al. 2021). Likewise, the present study is in contrast of the study conducted by Koirala D, Thapa N, Shrestha S in 2020 on Quality of life of postmenopausal women of Kaski district among 150 postmenopausal women where hot flushes was the most prevalent symptom of vasomotor domain (Koirala, Thapa, & Shrestha, 2020).
In this study, accomplishing less than used to (93.14%) was the most prevalent symptom of psychosocial domain. This finding is supported by the study conducted by Prajapati LM, Shrestha GK, Sanjel S in 2020 on Quality of Life of Menopausal Women in Majhifeda VDC, Kavrepalanchok, Nepal among 116 women which revealed that accomplishing less than used to as a major symptom of psychosocial domain (Prajapati, Shrestha & Sanjel, 2018). Similarly, this finding is contradicted with the study done by Thapa P, Thebe P on Quality of life of postmenopausal women in rural area, Nepal from July to November 2020 among 215 postmenopausal women which revealed that poor memory as a major symptom of psychosocial domain (Thapa & Thebe 2021).
In physical domain, feeling tired or worn out (98.04%) was the most prevalent symptom in this study. This finding is supported by the study conducted by Thapa P, Thebe P on Quality of life of postmenopausal women in rural area, Nepal from July to November 2020 among 215 postmenopausal women which revealed that feeling tired or burn out as the most prevalent symptom (Yerra et al. 2021). This finding is contradicted with the study done by Prajapati LM, Shrestha GK, Sanjel S in 2020 on Quality of Life of Menopausal Women in Majhifeda VDC, Kavrepalanchok, Nepal among 116 women which revealed that the most frequent symptom in physical domain was aching in muscles and joints (Prajapati, Shrestha & Sanjel, 2018 (Parajuli et al., 2021).

Menopausal Quality of Life in Different Domains
The descriptive statistical analysis of the present study shows that the overall median score for physical domain, psychosocial domain, vasomotor domain and sexual domain were 31(28,38), 12.50(10,15), 4(3,4) and 5(3,6) respectively. This finding shows that the most affected domain of menopausal quality of life was physical domain followed by psychosocial domain, sexual domain and vasomotor domain.
The above finding is supported by the study conducted by Koirala D, Thapa N, Shrestha S in 2020 on Quality of life of postmenopausal women of Kaski district among 150 postmenopausal women which revealed that the most affected domain of quality of life was physical domain followed by psychosocial domain, sexual domain and vasomotor domain (Koirala, Thapa, & Shrestha, 2020).

Difference in Quality of Life Domains with Selected Socio-Demographic Variables
The present study shows that there was statistically significant difference between vasomotor domain with marital status in which median score for others is more than married. Similarly, there was significant difference between vasomotor domain and occupation in which median score for homemaker is more than others. Whereas there was no any significant difference between vasomotor domain with age, marital status, educational status and duration of menopause at <0.05 level of significance. The above finding is in contrast with the study conducted by Prajapati LM, Shrestha GK, Sanjel S in 2020 on Quality of Life of Menopausal Women in Majhifeda VDC, Kavrepalanchok, Nepal among 116 women which showed that vasomotor domain has no significant difference with marital status and occupation (Prajapati, Shrestha & Sanjel, 2018).
The study shows that there was statistically significant difference between Psychosocial domain with marital status in which median and interquartile range is higher in others than married i.e., 16(13,20) and 11(9,14) at <0.05 level of significance. The above finding is supported by the study conducted by Parajuli SB, KC H, Mishra SK, Luitel A on Quality of Life among Postmenopausal Women: A Community-based Cross-sectional Study in 2021 among 200 postmenopausal women of Budhiganga Rural Municipality of Morang, Nepal which showed that there was statistically significant difference between psychosocial domain with marital status in which mean score was higher in others than married women (Parajuli et al., 2021). Also, the above finding is in contrast with the study conducted by Prajapati LM, Shrestha GK, Sanjel S in 2020 on Quality of Life of Menopausal Women in Majhifeda VDC, Kavrepalanchok, Nepal among 116 women which revealed that psychosocial domain has no significant difference with marital status (Prajapati, Shrestha & Sanjel, 2018).
Similarly, there was no significant difference between Physical domain with age, marital status, educational status, occupation and menopausal duration. This finding is similar to the study conducted by Prajapati LM, Shrestha GK, Sanjel S in 2020 on Quality of Life of Menopausal Women in Majhifeda VDC, Kavrepalanchok, Nepal among 116 women which shows that physical domain has no significant difference with age, marital status, educational status, and occupation (Prajapati, Shrestha & Sanjel, 2018). This finding is in contrast with the study conducted by Thapa A, Shrestha M, Pokharel N, Basnet T in 2021 on the Quality of Life of Menopausal Women in Dharan Sub-metropolitan City among 200 women which revealed that physical domain has significant difference with age in which mean score was higher in age group of more than 55 years than less than and equals to 55 years of age .
There was statistically significant difference between sexual domain with occupation. The above finding is in contrast with the study conducted by Parajuli SB, KC H, Mishra SK, Luitel A on Quality of Life among Postmenopausal Women: A Community-based Cross-sectional Study in 2021 among 200 postmenopausal women which revealed that there was significant difference between sexual domain with age in which mean score for more than 55 years of age was higher (Parajuli et al., 2021).

Conclusion
Based on the findings of the study, it concluded that the most common symptoms of vasomotor, psychosocial, physical and sexual domain were sweating, accomplishing less than used to, feeling tired or worn out and changes in sexual desire respectively. Among these domains, the most affected domain of quality of life was physical domain and the least affected domain was vasomotor domain.
The present study also revealed that there was statistically significant difference between vasomotor domain with marital status and occupation. Similarly, there was statistically significant difference between psychosocial domain with age and marital status. Likewise, there was significant difference between sexual domain with occupation. It was found that all the post-menopausal women were having at least one menopausal symptom from each domain. So, to reduce its impact on women's quality of life, they need special care and attention in their post-menopausal period and this can be achieved by education, creating awareness at both individual and community level and providing suitable intervention to improve the quality of life among postmenopausal women.

Recommendation
On the basis of findings of the study, the following recommendations were made: A similar study can be conducted in different settings and large sample using probability sampling technique.
Interventional study can be conducted among post-menopausal women.
The longitudinal study can be carried out on quality of life among post-menopausal women.