Official Journal of the College of Nursing, University of Mosul

Document Type : Original Articles

Authors

1 Department of Maternal and Neonatal Nursing, University of Raparin, Rania, Sulaimani, Kurdistan Region, 46012, Iraq

2 RAK College of Nursing, RAK Medical and Health Sciences University, Ras Al Khiamah, UAE

3 Department of Adult Nursing, College of Nursing, University of Raparin, Rania, Sulaimani, Kurdistan Region

Abstract

 Background: Menopause causes overwhelming physiological, emotional, and social dysfunction that has an impact on women's health. Women may experience compromised bodily functioning if they are unable to promptly identify and report any adverse effects. Many changes affect health, including vaginal dryness, hot flushes, sweating, and emotional changes. These symptoms are believed to be associated with women’s health. Women must possess appropriate knowledge concerning health conditions before the onset of menopause to promote wellness and prevent exacerbation of the effects of menopause. Objective: This study attempts to identify the level of Knowledge of Iraqi Kurdish women regarding Menopause phenomenon in the Kurdistan region of Iraq.
Methods: This cross-sectional study was conducted in the Kurdistan region of Iraq between November 12, 2021, and April 3, 2022. A purposive sampling technique was used for data collection and 130 women participated.
Results: Most (73.1%) participants were in the pre-menopausal period before the age of 40, while 45.4% claimed that menopause occurred after the age of 55. The majority (91.5%) believed that estrogen hormones changed during middle age. In addition, 20.8% of the participants had hypertension and feelings of anxiety. Most (74.6%) sought employment at their children's schools. Finally, a high percentage of the sample women had a moderate level of information.
Conclusion: Healthcare providers need to prepare and implement educational interventional programs to further educate women and prepare them to improve their health and well-being during this phase of their lives

Keywords

Introduction

Menopause is part of the aging process in women and is regarded as the finale of every woman’s best year, at which hormone production declines as a result of ovarian malfunction. Menopause has a direct impact on women’s physical, psychological, social, and emotional well-being. Globally, 500 million women aged 42–55 years have reported adverse experiences upon onset of menopause, and this number has been projected to increase to 1200 million by 2030 (Heer et al., 2020). The average age at natural menopause onset has been reported to be 51 years among women from the United States,(Shahzad et al., 2021) 48.5 years among Jordanian women,(Bustami et al., 2021) 51–52 years among Emirati women, 48 years among Iran women,(Tanha et al., 2021) and 48.9 years among women from Asian countries, such as China (Wang et al., 2021). After menopause, women are at a high risk for developing noncommunicable diseases, including cardiovascular diseases, diabetes mellitus, and cancer, which are the major causes of mortality among women worldwide (Wang et al., 2021).

The menopause phenomenon results from a decrease in estrogen production, which reduces the frequency of ovulation and remarkably alters the functioning of the reproductive system. The inability of ovaries to change the hormone levels leads to adverse symptoms, such as headaches, sleep disturbances, and mood swings, as well as vasomotor symptoms (e.g., hot flushes, night sweats, increased anxiety). Vasomotor symptoms such as night sweats and hot flashes are the only specific symptoms linked to menopause (Santoro et al., 2021). The immediate side effects of menopause are related to a deficit in estrogen, which is associated with health problems among women, including vasomotor symptoms, urogenital atrophy, osteoporosis, cardiovascular disease, cancer, and reduced cognitive and sexual functions (Eftekhar et al., 2021). The decline in estrogen levels contributes to the development of vasomotor symptoms, such as hot flashes and night sweats, which are considered the first symptoms of menopause experienced by 75% of premenopausal women (Peacock & Ketvertis, 2021). This process affects the temperature center of the brain (Viotti et al., 2021).

Menopause negatively affects women’s lives, and severe signs and symptoms may considerably affect not only their personal and social functioning but also their quality of life. In 2022, Özkan et al. conducted a comparative study between women in Turkey and Poland and reported that depression scores were higher among premenopausal women, whereas psychological health scores, social relationship scores, and environmental relationship scores were lower among Polish women (Özkan et al., 2022). The frequency and intensity of psychological, vasomotor, and somatic symptoms, which all have a significant negative effect on the quality of life, are higher during the perimenopausal stage (Górecka & Krzyżanowska, 2022). In Iran, women had reported experiencing severe adverse effects of menopause, which had affected their personal and social well-being and, thus, their health status (Nazarpour et al., 2020).

Menopause causes overwhelming physiological, emotional, and social dysfunctions that affect women’s health. Women may experience compromised bodily functioning if they are unable to promptly identify and report adverse effects. Several symptoms of menopause, such as vaginal dryness, hot flushes, sweating, and emotional changes, can affect women’s health (Muharam et al., 2021). Hence, women must possess appropriate knowledge regarding health conditions prior to the onset of menopause in order to promote their wellness and prevent the exacerbation of the effects of menopause. Such knowledge may enhance the understanding of normal changes, thereby facilitating the identification and differentiation of menopausal symptoms from other disease conditions (Hickey et al., 2022). Menopausal women may also identify critical information that would aid strategic programs to raise awareness and improve their quality of life (Kafaei-Atria et al., 2022). The possession of related knowledge will help women to embrace inevitable hormonal changes that could affect their psychological well-being, and women’s knowledge and attitudes related to menopause would aid in establishing coping strategies with a positive outlook. Furthermore, the deterioration of physical, mental, and emotional health among women motivates healthcare workers to develop health management strategies for coping with the adverse effects of menopause, and relevant knowledge will enable health practitioners to collaborate in determining and alleviating adverse signs and symptoms. These health management strategies could improve health conditions, thereby enhancing women’s quality of life.

Hormonal therapy is recognized as the standard treatment for hormonal dysfunction and has been proven to alleviate adverse signs and symptoms during the early stages of menopause. According to the vast majority of international consensuses, hormone therapy during menopause should aim at reducing the vasomotor symptoms and urinary atrophy. Menopausal women require a wide range of information, including information on cancer, clinical signs of menopause, and non-hormonal treatment options (Rees et al., 2022). In addition to pharmacological treatments, non-pharmacological interventions (e.g., maintaining a healthy lifestyle) are highly recommended by experts. Therefore, it is important for stakeholders to improve policies that cater to menopausal women’s wellness. Additionally, healthcare policies and decision-making must be reliable, sustainable, and accurate to improve women’s understanding and thus help them achieve peace of mind and happiness (Hassan et al., 2022). The provision of evidence-based information may help women to prepare for changes and transition, empower them to manage adverse menopausal symptoms, and inculcate confidence in facing challenges during the menopausal life stage (Wang et al., 2021).

The current population has changed its lifestyle, nutrition, and knowledge sources. An appropriate understanding pertaining to the occurrence of certain physical, mental, social, and psychological changes during menopause would help women to cope with these changes with better readiness.  A considerable number of women experience menopause without adequate understanding of the physiological changes and related symptoms, leading to feelings of instability and confusion. Hence, the acquisition of knowledge is imperative for women experiencing menopause in order to mitigate potential repercussions. Acquiring appropriate knowledge can result in a reduction of physical and psychological symptoms. The present study aimed to determine the level of knowledge regarding menopause among Iraqi Kurdish women in the Kurdistan region of Iraq.

Methods

Design and time frame of the study

This cross-sectional study was conducted on 130 women in the Kurdistan region of Iraq between November 12, 2021, and April 3, 2022. A purposive sampling technique was used for data collection. This study adhered to the STROBE reporting guidelines and checklist for observational research.

Setting and aim

A group of women from the Rania district in the Kurdistan region of Iraq participated in this study. This study attempted to evaluate the level of knowledge regarding menopause among menopausal women in the Kurdistan region of Iraq.

Sampling and sample size

As previously mentioned above, a purposive sampling technique was employed for data collection. Considering that no previous studies have examined women’s knowledge about menopause in the Kurdistan region of Iraq, the sample size for this study was calculated as 130 women, assuming a response rate of 50% with 95% confidence interval and error margin of 5%.

Inclusion and exclusion criteria

Women aged between ≥18 years and <60 years who agreed to participate in the study were included. Women aged <18 years or >60 years and those who were unable to communicate such as speech disorders were excluded from this study.

Study tools

In order to properly collect data and to achieve the goals, a questionnaire was constructed by thoroughly reviewing previous studies in the literature (Hassanzadeh et al., 2003; Noroozi et al., 2013; Nusrat et al., 2008; Shahzad et al., 2021). The questionnaire consisted of the following parts: Part I comprised the sociodemographic attributes of the sample (e.g., age, educational level, religion, marital status) and Part II pertained to women’s knowledge regarding menopause and comprised 22 multiple-choice questions covering all expected knowledge about menopause (e.g., definition, expected age, causes of death, signs and symptoms, side effects, hormonal changes, behavioral changes, lifestyle factors such as physical activity and exercise). A score of 1 indicated a “correct” response, whereas a score of 0 indicated an “incorrect” response. Consequently, the overall score ranged from 0 to 22, with scores of 17.1–22, 11.1–17, and 0–11 indicating better knowledge, moderate knowledge, and poor knowledge, respectively.

Validity and reliability

To accomplish the current goals, content validity analyses of the original instrument were conducted by a panel of 13 gynecologic and nursing specialists, who evaluated the questionnaire’s readability, usefulness, and completeness. A pilot study involving 20 female participants was performed prior to data collection. Pearson’s correlation was adopted as a method for measuring trustworthiness, and a total of 20 women were randomly selected using an evaluation instrument to determine the questionnaire’s accuracy. The interview was conducted with the women who composed the sample and was directed by the questions on the questionnaire (Ahmed, 2024). The test–retest method and Pearson's correlation coefficient were used to ensure a high degree of reliability and stability (r). Socioeconomic characteristics provided the basis for the correlations (r = 0.99 and r = 0.96). The findings of the pilot study indicated that each interview with one woman took approximately 20–30 minutes and confirmed that the questionnaire’s items were straightforward and useful. Additionally, the results of the pilot study showed that the questionnaire’s reliability in gathering data on midlife women was satisfactory. A scale was utilized to quantify and rank the questions regarding the scope of collected data.

Ethics approval

This study was conducted in accordance with the principles embodied in the Declaration of Helsinki and was approved by the College of Nursing Ethics Committee at the University of Raparin in the Kurdistan region of Iraq (approval no.: 7/22/2644; date of approval: September 8, 2021). Written informed consent was obtained from the participants after the researchers explained the aim of the study to them.

Statistical analysis

The data were organized and coded into computer files. Statistical analysis was performed using SPSS version 25 (IBM Corp., Armonk, NY, USA), and a statistician was consulted with regard to data analysis. Statistical significance was set at a p-value of <0.05. Data analysis was conducted using the following approaches and degrees of significance: (1) nonsignificant, p > 0.05; (2) significant, p < 0.05; and (3) highly significant, p < 0.00. One-way analysis of variance was used to compare knowledge levels and age groups. The dependent variable was women’s knowledge, and the independent variable was sociodemographic characteristics.

RESULTS

A total of 130 women participated in this study. As shown in Table 1, 46.2% of the participants had completed secondary school, 99.2% were Muslim, and 63.8% were married. Of participants, 20.8% had hypertension and anxiety, 4.6% reported pregnancy and preeclampsia, and 74.6% sought employment at their children's schools (Table 2). Participants aged 55–65 years accounted for 42.3% of the sample, and the majority (80%) of the participants regarded cardiovascular disease as a midlife disease. The participants identified more than one vasomotor symptom, with hot flashes (55.4%) and irregular menstrual cycles (33.8%) being the most frequently reported symptoms. Of the participants, 52.3% believed that they were in the premenopausal stage. As shown in Table 3, 73.1% of the participants were in the premenopausal period before the age of 40 years, whereas 45.4% claimed that menopause occurred after 55 years of age. Overall, 91.5% of women believed that their estrogen levels changed at midlife, 66.2% believed that estrogen and progesterone were commonly replaced hormones during midlife, and 46.9% believed that estrogen caused urinary tract atrophy.

Overall, 50% of the participants identified anovulation as the cause of noncyclic uterine bleeding (Table 4). Approximately 72% of the participants identified depression as the most common sign and symptom of psychological change. Furthermore, 63.1% of participants identified socioeconomic status as a factor influencing healthcare services, whereas 56.4% considered that psychological factors played a role in life. The majority (79.2%) of participants considered menopause to be a risk disease disorder. As shown in Table 5, 83.1% of the participants identified hypertension as a common midlife disease. At midlife, the majority of participants claimed to be taking vitamin D and calcium supplements. Among them, 77.7% deemed history screening as necessary and important to the nursing process, and 61.5% believed that chronic disease prevention was an important intervention for women. Hysterectomy (57.7%) was the most common surgical procedure performed at midlife among the participants (Table 6). Of participants, 98.5% considered physical activity as the most important intervention for preventing arthritis and osteoporosis, and 99.2% believed that reducing arthritis, osteoporosis, and cardiovascular disease was important to prevent weight gain. One-way analysis of variance indicated that women’s knowledge levels and their age groups did not significantly differ (F = 1.165, p = 0.330) (Table 7). Only 30.76% of the participants showed good knowledge, whereas 69.24% had moderate knowledge regarding menopause, menopausal symptoms, complications, and health management during this phase (Figure 1).

Table 1. Distribution of women’s demographic attributes.

Variables

Frequency

%

Age group

 

20–30 years

75

57.7

31–40 years

42

32.3

41–55 years

13

10

Educational level

 

Primary school graduate

10

7.7

Secondary school graduate

60

46.2

Institute graduate

29

22.3

Nursing college graduate

31

23.8

Total

130

100.0

Religion

 

Muslim

129

99.2

Others

1

.8

Total

130

100.0

Marital status

 

Single

44

33.8

Married

83

63.8

Without children and divorced

1

.8

With children and divorced

2

1.5

Total

130

100.0

 

 

 

Table 2. Sample distribution regarding information related to women’s health at midlife.

Items concerned with information

Menopausal women

Yes (n)

No (n)

Percentage of true answers

Women had hypertension and anxiety

27

103

 

74.6

Changes in women that occurred when their children finished school and left their home at midlife

97

33

Women were pregnant and had preeclampsia

6

124

 

 

36.2

Women’s age at menopause

 

 

35–45 years

28

102

45–55 years

47

83

55–65 years

55

75

Disease during menopause

 

 

 

 

80.0

Mental disease

11

119

Cardiovascular disease

104

16

Anemia

15

115

Symptoms of instability upon onset of vasomotor symptoms

 

 

 

Bradycardia

14

116

 

55.4

Hot flushes

72

58

Irregular menstrual cycles

44

86

Stage of women

 

 

 

 

6.9

Menstruation

53

77

Premenopause

68

62

Late menopause

9

121

 

Table 3. Sample distribution regarding information related to women’s health at midlife.

Items concerned with information

 

Period before the age of 40 years

Yes (n)

No (n)

Percentage of true answers

 

Menopause

18

112

 

73.1

Premenopause

95

35

Premature menopause

17

113

Menopause occurring after the age of 55 years

 

 

 

 

Late menopause

28

102

33.1

Postmenopause

43

87

Menopause

59

71

Hormones changed during menopause

 

 

 

 

Prolactin

11

119

 

91.5

Estrogen

119

11

Hormones were commonly replaced in menopause

 

 

 

 

Estrogen and progesterone

86

44

 

66.2

Prolactin

13

117

Adrenalin

31

99

Which hormone deficiency caused urinary tract atrophy?

 

 

 

 

Progesterone

33

97

 

46.9

Testosterone

36

94

Estrogen

61

69

 

Figure 1: Shows levels of knowledge of women about menopause phenomenon.

 


Table 4.
Sample distribution regarding information related to women’s psychological changes in life.

Items concerned with knowledge

Noncyclic uterine bleeding can lead to:

Yes (n)

No (n)

Percentage of true answers

Anovulation

65

65

 

 

50.0

Ovulation

46

84

Oocyte

19

111

Signs and symptoms of psychological changes

 

 

 

Fatigue

13

117

 

17.7

Depression

94

36

Mood disorder

23

107

Factors for healthcare services

 

 

 

Socioeconomic factors

82

48

 

 

20.8

Physical factors

27

103

Personal factors

21

109

Factors playing a role in life

 

 

 

Psychological factors

71

59

 

54.6

Social factors

48

82

Smoking and tobacco factor

11

119

Risk of health disorders

 

 

 

Low educational level

13

117

 

 

79.2

 

It’s disorder of risk of disease

103

27

Confidence in the belief that one has faith

14

116

 

 

Table 5. Sample distribution regarding information related to women's age at midlife.

Items concerned with information

Common chronic diseases in women at midlife

Yes (n)

No (n)

Percentage of true answer

Hypertension

108

22

 

83.1

Renal disease

20

110

Hepatic disease

2

128

Diet during menopause

 

 

 

Vitamin D and calcium supplements

65

65

 

 

50.0

High fat and cholesterol

42

88

High sodium

23

107

Necessary and important to the nursing process

 

 

 

History screening

101

29

 

 

77.7

Physical examination

28

102

Surgical process

1

129

Important intervention for women

 

 

 

Prevention of chronic diseases

80

50

 

61.5

Provision of information and knowledge

36

94

Health promotion

14

116

 

Table 6. Sample distributions regarding women's lifestyle at midlife.

 

Items concerned with information

Common surgical operations in women at menopause stage

Yes (n)

No (n)

Percentage of true answers

Cystectomy

46

84

 

Appendectomy

9

121

 

Hysterectomy

75

55

35.4

Physical activity as the major protection

     

Reduction of arthritis or osteoporosis

128

2

98.5

Prevention of renal diseases

2

128

Important to prevent weight gain

   

 

Reduction of arthritis/osteoporosis and cardiovascular disease

129

1

99.2

Prevention of gastrointestinal disease

s1

129

 

 

 

Table 7. Comparative differences in women's knowledge levels and age groups.

Age groups

N

Mean

Std. deviation

F value (one-way ANOVA)

p-value

20–26 years

48

13.81

2.711

1.165

0.330

27–33 years

36

12.92

2.156

34–40 years

26

13.08

2.622

41–47 years

16

13.81

2.040

48–54 years

2

16.00

2.828

≥55 years

2

13.50

0.707

Total

130

13.45

2.469

ANOVA, analysis of variance.

 Discussion

While menopausal transition varies among different ethnicities, it usually occurs at the age of 45–55 years (Lancet, 2022; Schoenaker et al., 2014). Several factors influence the age at menopause, including but not limited to the maternal age at menopause, alcohol consumption and tobacco smoking, physical activity level, dietary habits, and socioeconomic status (Ceylan & Özerdoğan, 2015). During this period, women experience numerous physiological and psychological changes and encounter diverse stressful events or challenges, such as family problems (e.g., divorce, death, taking care of parents, having children), balancing work and personal life, and work-related issues (e.g., career goals, frustrated goal attainment, securing financial resources) (Smith-DiJulio et al., 2008; Thomas et al., 2018). Appropriate actions to increase awareness about menopause and how to deal with related problems are recommended to prepare women for this phase in their lives (Maharrshi et al., 2022; Shahzad et al., 2021).

The present study aimed to evaluate the level of knowledge regarding menopause among Iraqi Kurdish women. Our results indicated that only 30.76% of the participants had good knowledge, whereas 69.24% had moderate knowledge about menopause, menopausal symptoms, complications, and health management during this phase. These findings are consistent with the results of similar studies conducted in Iran,(Thapa & Yang, 2022) northern Taiwan,(Tsao et al., 2004) and the United Arab Emirates (Smail et al., 2020). However, in contrast to previous studies conducted on African-Americans(Sharps et al., 2003) and middle-aged Danish women,(Køster, 1991) the participants in the present study showed satisfactory or good knowledge about menopause.

An earlier study reported that women often lacked understanding about perimenopause and that the menopausal transition usually started at 5 years before menopause (El Khoudary et al., 2019). In the present study, 73.1% of the participants correctly identified the premenopause period, whereas only one-third of the participants correctly identified the menopause (36.2%) and postmenopause (33.1%) periods.

The menopausal transition is a period of marked hormonal instability and exhibits striking variations in the levels of ovarian hormones, mainly estrogen, progesterone, and testosterone. Because of these hormonal changes, women may experience a wide range of symptoms such as depression, mood swings, urogenital symptoms, sleep problems, and vasomotor symptoms (Hajesmaeel-Gohari et al., 2021). In the current study, 91.5% of the participants correctly identified estrogen as the main hormone that causes changes at midlife, and only 46.9% of the participants identified estrogen as the hormone responsible for causing changes in the urogenital system. Of all participants, 55.4% identified hot flashes as symptoms of vasomotor instability. Depression, mood disorders, and fatigue were the manifestations commonly observed at midlife in 57.69%, 17.7%, and 10% of the study participants, respectively. Similar to the findings of the present study, earlier studies reported hot flushes, night sweats, vaginal dryness, fatigue, and joint pain as the common problems encountered during menopause (Chen et al., 2015; Santoro et al., 2015). Similar to earlier reports, nearly two-thirds (74.6%) of the participants in our study claimed that their major concern was that women often sought employment at their children's schools, thereby leaving home.

Midlife estrogen and progesterone levels fluctuate, increasing the risk of certain health problems such as heart disease, stroke, genitourinary problems, depression, and osteoporosis (Georgakis et al., 2016; Johnson et al., 2015). Several factors play a role in the development of these complications. In the present study, 80%, 11.54%, and 8.46% of the participants considered cardiovascular disease, anemia, and mental disease as major health concerns during midlife, respectively. More than one-third (77.7%) of the participants recognized the importance of screening for the prevention of chronic diseases. However, only 61.5% of the women believed that interventions to prevent chronic diseases were important during this period. Only half (50%) of them were aware of the type of diet to be followed during midlife, and most of the study participants reported that physical activity could reduce arthritis and osteoporosis (98.5%) and that preventing weight gain would provide protection from osteoporosis and cardiovascular disease (99.2%).

Seeking healthcare advice as a preventative method is an ideal way to enhance the quality of life and avoid complications. In many societies, women are disadvantaged owing to discrimination rooted in sociocultural factors. Hence, it is particularly important to recognize factors influencing health-seeking behaviors to develop plans for improving the utilization of healthcare services, particularly among women. A previous study reported a significant association between health-seeking behaviors among women and educational level, occupation, and household income (Myint et al., 2021). The majority of the participants in the present study identified socioeconomic factors as important factors influencing health-seeking behaviors and considered psychological factors as important factors playing a major role in life.

This study has a few limitations. First, the findings of this study are limited to midlife women in the menopausal transition stage and, hence, cannot be applied to the general population. Second, there was a possibility of recall bias, as this was a cross-sectional study.

Conclusion

The findings of this study suggest that Iraqi Kurdish women have a remarkably low level of knowledge about menopause and how to manage common problems that occur during this period. Healthcare providers should plan and implement intervention programs to educate women and improve their health and well-being during this phase of their lives.

 

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles embodied in the Declaration of Helsinki and was approved by the College of Nursing Ethics Committee at the University of Raparin in the Kurdistan region of Iraq (approval no.: 7/22/2644; date of approval: September 8, 2021). Written informed consent was obtained from the participants after the researchers explained the aim of the study to them.

 

Consent for publication

Written informed consent for publication was obtained from the participants.

Author contributions

RMK, Conceptualization; RMK, Data curation; SKA Formal analysis; SKA and, MGM Investigation; SKA, Methodology; SKA, RMK, Project administration; SKA, MGM, RKR, and NO Writing—original draft; SKA, MGM, RKR, and NO Writing—review & editing.

Acknowledgments

The authors express their heartfelt gratitude to all individuals who participated in the study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare that they have no competing financial interests or personal relationships that may have influenced the work reported in this study.

 

Availability of data and materials.

All data reported in this study are available from the corresponding author upon reasonable request.