BMS / RCOG Theory Course : POST MENOPAUSAL HEALTH Spring 2006

Cultural Issues & the Menopause

Joan Pitkin BSc FRCS FRCOG

Northwick Park & St Marks Menopause Clinical & Research Unit

BMS / RCOG

‘ Culture is a set of guidelines ( both explicit & implicit ) which individuals inherit as members of society, and which tells them how to view the world, how to experience it emotionally and how to believe in it in relation to other people, supernatural forces or God and the natural environment. ’

Ritcher JMA J Psychosom Obstet Gynaecol 1997 8181-86

1

CHANGING POPULATION Changing population due to increasing life expectancy and falling fertility rates:

1955

Average life expectancy 48yrs

2002

Average life expectancy 68yrs

2025

Predicted life expectancy 73yrs

GLOBAL POPULATION NOW 6.1 BILLION

8 BILLION

1

THE RELEVENCE OF THE TOPIC • Given that 467 million women were postmenopausal in 1990, how many will be postmenopausal by 2030 :.

n

800 million

o

1000 million

p

1200 million

2

CHANGING POPULATION • IN THE NEXT 20 YRS

18% increase in the >75yrs of age 38% increase in the >85yrs of age - there are more than 12million women > 45yrs in the UK (i.e. 20% of the population) - a woman’s average life expectancy in Britain is 79yrs i.e. 30yrs apprx. post menopausal life

2

THE RELEVENCE OF THE TOPIC .

• The major increase will be in :

n

Developing nations

o

Developed societies

WHO Report Series 866

3

2

THE RELEVENCE OF THE TOPIC • The major increase will be in :

CHINA ALONE WILL MAKE UP 23% OF THE GLOBAL POSTMENOPASUAL POPULATION

WHO Report Series 866

3

THE RELEVENCE OF THE TOPIC Are the ages of menarche & menopause variable between races ?

Does the age of menarche & menopause change if uprooted from one society to another ?

/

/

X

X

?

?

4

DEMOGRAPHY • An international variability study done across 11 countries & 5 continents involving 18,000 women revealed : • Median age of menarche 14yrs • Median age of menopause 50 yrs

Morabia A et al Am J Epidemiol 148 1998 1195 -1205

• A study done on British Asian women born

in India but living in UK 10-20yrs revealed : • Median age of menarche 14yrs • Median age of menopause 48 yrs

Sethi K Pitkin J Climacteric 2000

SWAN STUDY • Japanese women have significantly later • • •

menopause Hispanic have an earlier menopause Current smokers have earlier menopause by 1-2yrs than never or previous smokers Other factors :– nulliparity – never COC usage – low education Gold EB et al Am J Epidemiol 2001

5

BMS /

RCOG

Perimenopausal healthcare remains fragmented :

• Menopause is a normal transition • Majority of women do not seek help for this transition • Resources differ between regions

4

WHAT RACIAL GROUP ARE YOU ? .

n o p q

Caucasian Afro Caribbean Asian Other

6

5

Are attitudes to the menopause altered by social factors? .

/

X

?

5

Are attitudes to the menopause altered by social factors ?

/

X

Caucasian Afro Caribbean Asian Other

?

7

Psychosocial determinants of Women’s Responses during the Climacteric • Marital Relations - existing marital problems are likely to be longstanding, little evidence to confirm problems begin with climacteric - importance of stable, intimate relationships stressed in coping with life events - women reporting poor marital relationships had increased risk of psychiatric disturbances Brown & Harris 1978,

Ballinger et al 1975, McKinley 1987

- Relation between marital status, stress & menopausal symptoms Jiminez 1997, Gannon & Stevens 1998

Psychosocial determinants of Women’s Responses during the Climacteric • Sexual Relations - Swedish Study 800 women looked at effects of age and menopause separately significant decline in sexual interest in post menopausal gp. – independent of increasing age artefact: “menopause as an excuse “ Hallstrom 1977

- British study, 436 women, 35-59yrs sexual dysfunction increased with age positive association with marital disharmony & psychiatric disorders Osborne 1988

8

Psychosocial determinants of Women’s Responses during the Climacteric • Children leaving home : - “ Empty Nest Syndrome “ Deykin et al 1966

- women who reported a child had left, or married in the preceding year, were more likely to show evidence of psychiatric disturbances Ballinger, 1975

- 160 women expressed relief when children left home, especially of they did so in an acceptable way. Rubin 1979)

Psychosocial determinants of Women’s Responses during the Climacteric * Influences of Society - Women expressed anxieties about their future as individuals, returning to work, retraining etc. ( Rubin 1979 ) - fear of aging & difficulty managing - death of parents – minimal effect responsibility of carer – bigger effect - low socio-economic status low income low educational levels limited employment prospects Jaszman et al 1969

9

6

Social Factors & Ethnicity Who is least likely to smoke ?

Which group has highest parity ?

n

Caucasian

n

Caucasian

o

Afro-American

o

Afro-American

p

Japanese

p

Japanese

q

Chinese

q

Chinese

6

Social Factors & Ethnicity Who has highest education levels ?

Who has lowest education levels ?

n

Caucasian

n

Caucasian

o

Afro-American

o

Afro-American

p

Japanese

p

Japanese

q

Chinese

q

Chinese

10

6

Social Factors & Ethnicity Who has highest BMI ?

Who has highest physical activity levels ?

n

Caucasian

n

Caucasian

o

Afro-American

o

Afro-American

p

Japanese

p

Japanese

q

Chinese

q

Chinese

STUDY OF WOMENS HEALTH ACROSS THE NATION ( SWAN ) • Community based survey conducted 19951995-1997 • Multi racial / ethnic sample 16,065 women , 4040-55yrs • Seven sites across USA, each site screening minority population + Caucasian population

• Aims

• African Americans - Pittsburgh, Boston, Detroit, Chicago • Japanese – Los Angeles • Hispanics – New Jersey • To screen women for eligibility to enrol into longitudinal study of post menopausal women

• To investigate cross sectional relations of a number of risk factors & health outcomes

Gold EB et al Am J Epidemiol 2000 152 463- 473

11

STUDY OF WOMENS HEALTH ACROSS THE NATION ( SWAN ) • Age distributions similar by race / ethnic groups • • • • • • • • •

– higher proportion of Chinese women 4040-43yrs & a lower proportion were 5252-55yrs. Most women were pre menopausal or early perimenopausal Proportion of surgical menopause higher in African Americans Proportion of postmenopausal women were higher in Hispanics Educational attainment – highest in Caucasians – lowest in Hispanics Japanese & Chinese women had the least difficulty paying for basics Smoking rates were lowest in Japanese & Chinese women Parity was highest in AfricanAfrican-Americans & Hispanics BMI highest in AfricanAfrican-Americans Perception of Physical Activity similar for all groups Gold EB et al Am J Epidemiol 2000 152 463- 473

SWAN Multivariate adjusted association of risk factors to symptoms • Age ::- All symptoms increased with age, except urinary leakage & vasomotor symptoms

• Hormonal ::- Largest adjusted prevalence odds ratio for all symptoms ( OR 2.06 -4.32 ) was for peri or post menopausal women

• BMI ::- Hot flushes / night sweats

• urinary leakage if BMI > 27 • stiffness of jts • urinary leakage x 2 if BMI > 32

• Smoking ::- Past & current smoking related to prevalence of all symptoms – except vaginal dryness & forgetfulness

• Exercise : - All symptoms worse as activity levels Gold EB et al Am J Epidemiol 2000 152 463- 473

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SWAN Multivariate adjusted association of risk factors to symptoms • Socio – Demographic :Difficulty Sleeping

P/V Forgetfulness dryness

Heart Hot flushes flushes pounding night sweats sweats

Urinary leakage

Stiffness

Low educational attainment

High financial difficulty

No full time employment

OR women difficulty paying for basics 1.15-2.05 Gold EB et al Am J Epidemiol 2000 152 463- 473

How best to conceptualise the Menopause The Biomedical Model • Focuses on biological aspects •Identification of symptoms

Social Scientists * Social & Cultural Construct of the menopause

•Via cross-sectional studies of general population in 1970s & 80s Via longitudinal studies in 1990s

“ A natural event “ Fragmentation of the Woman

13

7

Does ethnicity alter the physical & biological experience of the menopause ? .

/

X

?

7

Does ethnicity alter the physical & biological experience of the menopause ? /

Caucasian

X

Afro Caribbean Asian Other

?

14

SWAN Multivariate adjusted association of risk factors to symptoms • Race / Ethnicity:Difficulty Sleeping

P/V Forgetfulness dryness

Heart Hot flushes flushes pounding night sweats sweats

Urinary leakage

Stiffness

Japanese/Chinese

African/American

Hispanic OR cf Caucasian Japanese / Chinese 0.47 -0.67 African/American 1.17 -1.63 vasomotor symptoms + p/v dryness

Gold EB et al Am J Epidemiol 2000 152 463- 473

BMS /

0.64-.0.72 leakage & poor sleep Hispanic

1.22-1.85 Vag. dryness forgetfulness, heart, leakage

RCOG

INCIDENCE OF VASOMOTOR SYMPTOMS • • • • • • • • • • •

Indian Rajput Women Indian Varsani Women Canadian Sikh Women Mayan Women Hong Kong Women Japanese Women Thai Women N. American Women Dutch Women British Women Australian Women

0% 61% 0% 0% 10 -22% 17% 23% 45% 80% 54% 39% Sethi K European Congress on Menopause July 2000 ICS 1229 ( 2002) 207-214

15

VARIABILITY IN SYMPTOMS ACROSS DIFFERENT RACES • Less vasomotor symptoms in Asians, especially Japanese • Lock M et al Maturitas 1988 • Flint MP et al J Biosocial Sci 1979 • Lock M Kaufert P Am J Human Biol 2001

• Shoulder stiffness in Japanese women • Lock M et al Maturitas 1988

• Vulval irritation & U/G symptoms in Indian women • Sharma VK et al Maturitas 1981

• Headaches in Thai & Koreans

• Punyahotra et al Maturitas 1997

• Asymptomatic in N. India

• Flint M Smail RS Annals of N York Acad Sci 1990

• More symptoms in Turkish immigrants than Germans • David M et al Zentralbl Gynakol 2001

SWAN STUDY HAS SHOWN DIFFERENCES IN HORMONE LEVELS

SWAN Update • Serum estradiol & SHBG levels lower in Japanese & • • • •

Chinese women Serum testosterone lower in Hispanics Serum DHEAS higher in Chinese, Japanese & Caucasians FSH levels no different in ethnic groups – correlated with menopausal status All hormone levels significant correlation with body composition.

Randolf JF Jnr et al J Clin Endocrin. & Metab. 2003

16

SWAN Update • African American & Hispanic women have significantly higher prevalence of hypertension cf Caucasians

– Chinese & Japanese have similar prevalence cf Caucasians (independent of other factors) – BMI & waistwaist-hip ratio also important Lloyd-Jones DM et al Hypertension 2005

• African Americans reported greater stress & had higher carotid intimaintima-media thickness (IMT) cf Caucasians

Troxel WM et al Health Psychology 2003

SWAN Update • Significant racial differences in the effects of sociosocio-economic status on weight:weight:-

– African American women at all levels of education were equally heavy – Caucasian women were thinner the higher the educational status – Over time women of both races and all educational levels gained weight equally (1.3lbs p.a.) Lewis TT et al Archives of Int Med 2005

• Influences on BMI:BMI:– Physical activity & ethnicity were biggest factors – Women who were hyserectomised were heavier – Women on HRT were lighter Mathews KA et al Obesity & Related Metab Disorders 2001

17

SWAN Update • Association of depression & elevated risk of

developing diabetes over 3yrs f/u + increases in insulin resistance in African American gp alone Everson-Rose SA et al Diabetes Care 2004

• OA knee present by 40yrs in 23.1% black cf 8.5% whites

– Prevelance in hands were comparable – but different joints were effected. Sowers M et al Osteoarthritis & Cartilage 2000

8

Does ethnicity alter attitudes to the menopause ? .

/

X

?

18

8

Does ethnicity alter attitudes to the menopause ? /

Caucasian

X

Afro Caribbean Asian Other

?

BMS /

RCOG

MENOPAUSE – A REWARD • Rajput women come out of purdah and may sit with men • The Qemant Ethiopian women can visit sacred sites and handle ritual food and beverage

• Hutterites of S. Dakota are relieved of heavy agricultural labour & are treated with respect in their extended families

• Ulithi ( Micronesia ) women may become healers • Bantu women in S. Africa can proceed to purification of the weapons weapons of the warriors

• Respect & veneration of middle aged women in • • • •

Micronesia Turkey Tiwi women of Australia Magars of Nepal

Flint M Psychosomatics 1975 161-163

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BMS /

RCOG

MENOPAUSE – A PUNISHMENT • • • • • • •

Race against time Sexual promiscuity aimed at proving desirability Fear begins at 40yrs and downhill after that Empty nest syndrome Aggravation of psychoneurotic tendencies A decrease in stress tolerance Fear of loss of femininity

Flint M Psychosomatics 1975 161-163

CULTURAL DIFFERENCES IN ATTITUDE TO MENOPAUSE POSITIVE

• Korean – natural event

• E. Asian Consensus Mting 1997

• Thai – normal part of aging

• Wang JF Reflections 1997 • Fu SS-Y, Anderson D Nurs Health Sci 2003

NEGATIVE

• Italian

• Gifford SM Cult Med Psych 1994 • Temple Smith M et al Health Prom J Aus 1995

• Genazzani AR et al Maturitas 2002

• Traditional societies in general

• W Culture - sense of loss

• Asian cultures

• Arabs saw more problems ( 26% ) than

• McMaster J et al Womens Health 1997 • Li S et al Clin Nurse Spec 1995

• African Americans v. positive (Chinese Americans most negative)

• Sommer B et al Psychosom Med 1999

• Bannister EM Qual Health Res 1999

Jews ( 7.7%)

• NirNir-Caein R et al Clin Exp Obstet Gynaecol 2002

• Veranasi, Veranasi, India

• Sharma VK et al Maturitas 1981

20

SWAN Update • Caucasian women primarily concerned about

menopause as it altered physical appearance – social ideation of youth – African American women viewed menopause as normal – even welcome! Sampselle CM et al Health Care for Women Int 2002

• African American women reported a greater

sense of security & identity especially if under

stress or greater financial need

Brown C et al J of Applied & Social Psychol 2005

SWAN Update • In adjusted analysis odds of distress were significantly higher in Caucasians Bromberger JT et al Am J Pub Health 2001

• Caucasian women report more psychosomatic symptoms Afro Americans report more vasomotor symptoms Avis NE et al Social Science & Medicine 2001

21

SWAN Update • Latino women emphasise 3 themes :-

• The primacy of health & importance of harmony & balance • El cambio de vidu – ‘ something you have to go through’ • This time is for me – reorientation & restructuring

Villarruel AM et al Research & theory for Nursing Practice :- An Int J 2002

9

On a scale of 1 : 5 which of the following is most ( 5 ) / least ( 1 ) likely to support menopause change ? .

Traditional Society

Modern Society

Transitional Society

22

Socio-Cultural determinants of Women’s Responses during the Climacteric • Social consequences of menopause in different societies influence attitudes to it - in traditional societies loss of reproductive function often obviated by alternative social roles consequences confined to direct biological & physical consequences - Malaysia 80% of women said they saw no need to consult a doctor re menopause - Indonesia only 36% of women had seen a doctor - conversely “ losing face “

Kim WW 1999 Sharma VK, Saxena MSL 1981

- in modern societies often putative social & psychological sequelae “ Western Image “

Maoz B, Dowty N, Antonovsky A et al 1970

Socio-Cultural determinants of Women’s Responses during the Climacteric • Factors impacting on negative Western attitude - Age, negativity stronger at younger ages

- Social class, changes away from negative attitude in last 10-20 yrs in higher socio-economic groups

- Extent to which the woman values her reproductive role

23

Socio-Cultural determinants of Women’s Responses during the Climacteric • Attitudes to menopause more adverse in societies still in transitional phase -

idiosyncratic mores of culture, or subculture religious beliefs vs speed and impact of modernisation - Japan

Namihira E 1999

- British Asian Women only 33% happy about menopause > 46% frightened

Sethi K, Pitkin J. 2000

- Vietnamese Community, Melbourne Australia Jean Hailes Foundation

BMS /

RCOG

HOW DIFFERENT TYPES OF WOMEN COPE • 3 clusters identified : – Suffering women ( 27%) who have : • low selfself-esteem • high unemployment rates • low educational status

¾ have marked symptoms ¾ usually seek medical advice

-

Pragmatic women ( 37%) have good levels of self-esteem

¾ not seriously effected by menopausal symptoms ¾ cope through self-discipline - Self-conscious women ( 26%) have good levels of self-esteem and are extrovert in nature ¾ experience an average number of complaints ¾ sometimes seek medical advice After Rosemeir XV.FIGO World Congress Aug 1997

24

UG DR

f no tur ms Re pto m sy

S OR ion oft CT rat en Du eatm FA tr

se y Do enc qu fre

PATIENT FACTORS

ADHERENCE/ NONNON-ADHERENCE

Q p a ualit y t re ient of lat /do ion ct sh or ip

Quality Severity of of life symptoms

Re g fo ula re- llow rity en -u of fo p o ta k f be rce and ing nef me th its t nt er ap o y

Personality/ moods

FA CT OR S – h alit ow y o to f e – – t ben tak xpla ail efi e m na or t s ing an edi tion: th e d ri catio ra sks n py to

cts ffe e e red Sid cur in

PH YS IC IA N Qu

Organised/ disorganised

e ion ) s us rat of nist tion i c se Ea adm stru f in eo g ut gin (ro cka pa Un an ders d ta to com ndin ad m he itm g of re nc e n t e

t en em s ov om pr pt Im sym in

BMS /

Education Cognitive level function

P dia reci g s pr nos ion o es cri is an f bin d g

Age Expectations/ Health satisfaction beliefs beliefs

Adapted from McGavock

RCOG

Q o L

Socio-Economic

Attitude to Menopause

Socio-Cultural

25

BMS /

RCOG

CONCLUSIONS l • The concept of Menopause as an illness or moment in life depends upon : – – – – –

knowledge of health biography personality culture family traditions

• Most symptomatology is in perimenopausal & immediate •

post menopausal phases Generalisations are unhelpful – attitudes vary between cultures and within the same culture at different times

BMS /

RCOG

CONCLUSIONS ll • Degree of symptomatology depends on whether there is a positive or negative attitude to menopause

• Suffering women are more likely to seek help • A negative attitude to the menopause does not automatically mean women will take HRT

• A positive attitude to the menopause means women

remain to be convinced & need positive proof of benefit of HRT

26

BMS /

RCOG

CONCLUSIONS lll • There is a worldwide demand for information and education on menopause & HRT

• Women want more than a description of biological change

• Information & education has to be culturally sensitive & appropriate to the level of understanding of the woman

• Physician attitudes are very important in womens decisiondecision-making process

Postmenopausal Health Joint RCOG/BMS Special Skills Meeting

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