Vol-7, Special Issue-Number4-July, 2016, pp690-700
http://www.bipublication.com
Research Article
“Menopause: two sides of the same coin”: A qualitative study
1
Mansoureh Yazdkhasti, 2*Reza Negarandeh
and 1Zahra Behboodi- Moghadam
1
Department of Reproductive Health,
School of Nursing & Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2
Department of Nursing and Midwifery Care Research Center,
Tehran University of Medical Sciences, Tehran, Iran
*
Corresponding author: rnegarandeh@tums.ac.ir
ABSTRACT
Background: Menopause has been identified as a public health problem, which has fundamental consequences on women’s physical, mental, and reproductive health. Healthcare providers play significant role in supporting post-menopausal women. This study was designed with the aim of understanding the experience of menopause among Iranian women.
Methods: Content analysis approach was used to design this qualitative study. Participants were 19 menopausal women, selected from four menopause clinics in Tehran, Iran. Purposive sampling method was applied to recruit the study participants and continued until data saturation was reached. Semi- structured interviews were employed to collect data. Transcripts were coded using a five-step process, and then compared with each other to identify categories, subthemes and theme. MaxQDA Software was used to organize the data.
Results: During the data analysis, 732 initial codes were clustered in ten categories and two subthemes. “Paradoxical experiences” was one theme emerged through data analysis. The participants of our study referred to menopause as a natural life phase could be considered as two sides of the same coin.
Conclusions: Menopause was thought to be a natural process which was characterized by positive and negative features. Understanding these features and their implications in these women's lives may assist healthcare workers in helping their clients with menopause.
Keywords: Menopause, Qualitative study, Content analysis
BACKGROUND
Menopause may be regarded as a developmental stage in the life cycle [1]. Although the biomedical view stresses atrophic and degenerative changes, a developmental and holistic perspective stresses the individuality, totality, and complexity of responses to this experience[1, 2]. Menopause, as a complex and multifaceted phenomenon, is also known as the "second maturity" [3]. The number of post-menopausal women in the USA in 1990 is
The socio-cultural contexts within which they live lead to a different conceptualization of menopause [4].In fact, the experience of menopause is unique to each individual, and its meaning differs among women [9-14]. European / Saxon women describe it as a most distressing event that threatens health and feminine identity.
Most of them regard these phenomena as the beginning of aging and loss of physical control. They try to recover and manage own feminine identity [15].Women in the culture of northern India welcome it because women in their postmenopausal years have special place in the society. So that menopause as a natural phenomenon brings a sense of respect as well as a sense of freedom and more social interactions [16,17]. In Iran, Some women experience a profound sense of loss at menopause (e.g. loss of femininity, youth or beauty) which may lead them to feel that life has lost its purpose [18]. A qualitative research in Turkey showed that getting old, loss of sexual interest and vasomotor symptoms were negative experiences in menopausal women. Emotional instability or irritability is among the prevalent complaints and lack of family support seemed to worsen mood swing [19,20].
In spite of extensive research on menopausal symptoms and its psychosocial aspects, little is known about the personal meaning or view of menopause as experienced by Iranian women and there was less comprehensive definition for Menopause experiences. This qualitative study was designed and performed with the aim of understanding the experience of menopause among Iranian women.
METHODS
Design of the study
This was a qualitative study based on a content analysis approach. Content analysis is different from objective information extracted from textual data. Indeed content analysis will help to uncover the hidden themes and patterns [21].
The aim is to reach a broad and condensed description of the phenomenon under study, and the outcome of the analysis is categories or themes describing the phenomenon.
Qualitative content analysis is the best method to study cultural context-bound subjects [21, 22].
Sampling and study setting
19 participants were recruited based on purposeful sampling. The strategy of maximum variation by characteristics such as age, marital status, education, number of children, economic status and employment status was used. Sampling was continued till data saturation. Characteristics of participants are reported in Table 1.
Women were recruited via four menopause clinics affiliated to Tehran University of Medical Science. Information about the study was available in the menopause clinics and women were given verbal information by midwives. Women who gave their permission were then contacted by the first author. They were provided with written information about the study and an opportunity to ask questions.
The inclusion criteria were: 1) postmenopausal women aged 45-60 years 2) natural menopause and/or surgical menopause, 3) Speaking Persian, 4) Consent of participants in the research. Exclusion criteria were: 1) unwilling to talk about menopausal experiences, 2) withdrawal during the study, 3) having speech or hearing problems.
Data collection
Each interview lasted 30-90 minutes (on average 57 min).
Data analysis
The conventional content analysis approach was applied to explain the phenomenon of menopause by examining real world experiences of women. Analysis was done concurrently with data collection using the 5-step method for analysis of qualitative data described by Graneheim and Lundman [21], as follows:
1. Interviews were transcribed verbatim and reread several times to gain an overall understanding of their content;
2. Text was divided into condensed meaning units;
3. Condensed meaning units were abstracted and coded;
4. Codes were compared based on similarities and differences and classified into
Categories and subcategories reflected the manifest content of the text;
5- Re-organizing and merging into subthemes and over arching themes as the expression of the latent content of the text Participant.
In this study, the analysis progressed until the manifest content was clarified and the theme, sub theme and categories were determined. MaxQDA Software was used to organize the data.
Trustworthiness
The four criteria including credibility, dependability, conformability, and transferability as described by Lincoln and Goba were used to ensure the trustworthiness of the findings [22]. Researchers increased credibility of the data by establishing a close rapport with participants, checking up via member check, peer debriefing, and considering the maximum variationin sampling. Member checking was achieved by asking the participants to verify the preliminary findings from the earlier interviews. In peer debriefing, the process of analysis was reviewed among members of the research team including; first author and two expert coauthors. During regular meetings and if there was a disagreement,
the review continued to reach an agreement. Establishing a close rapport with participants was done by the first author in order to build the participants trust and gather in-depth data. The external audit technique enhanced . Dependability and conformability. During the external audit, texts of the interviews and the codes and categories extracted from them were examined by two experienced researchers in qualitative research who were selected outside the research team. They confirmed the correctness of the analysis, as well. Transferability was ensured by comparing the similarity of findings with the experiences of non-participants and achieving maximum variation among participants.
Ethical Considerations
Ethical considerations in this study included allowing them to freely participate in the research, obtaining the written consent of participants, observing confidentiality and anonymity. Also, audio recording permission was taken from the interviewees.
The interviewer was not involved in the participants’ healthcare. Approval of Ethics Committee was received from Tehran University of Medical Science in 2 December 2013 with NO: 9121151011-147562.
RESULTS
During the data analysis, 732 initial codes were clustered in ten categories and two subthemes. “Paradoxical experiences” was one theme emerged through data analysis (Table2). Below is a more precise presentation of the results.
Paradoxical experiences
Opportunity
In this study, Opportunity was defined as the women's positive experiences of menopause. Menopause was a time for growth and development that provided new opportunity to redefine life. Five categories of this sub-theme were wisdom development, social development, Eagerness to learn, peace of mind and self -attention.
Wisdom development
Menopausal women expressed rational thinking in dealing with issues.” Since menopause, I think on issues more than ever before, I was superficial person and did not make myself worry about any of the things … I think more than before on the subjects, and try to rational thinking “(Participant 15).
Interpersonal support
The participants expressed interpersonal support as the effective and friendly social relations with peers. “I have more time to communicate with my friends in my age who are going through menopause, like me” (Participant 11). In this way they talked about their problems sharing own knowledge with each other and using experiences. “After praying in the mosque we gather talking to each other. For example I say that overwork makes my knee pain since going through menopause….my friends say we too. I mean we share our knowledge and experience together “(Participant 8).
Eagerness to learn
The participants defined menopause as a stop in one's life to weigh her life, reviewing past interests and favorites. “I am broadly interested in science of Temperament. Hence, menopause gave an opportunity to study it... I've always wanted to do it but I lost time due to busy life. Now I am more satisfied with myself” (Participant 1). Peace of mind
The participants were not worry about cleanliness of body when praying and go to pilgrimage to the holy places. “Before menopause, when we wanted to go to pilgrimage I'd always worry about my menstruation date. Because I had irregular
bleeding, then I missed the pray ….or go to shrines, then I relieved and I feel cleanand freedom” Participant (9).
Self -attention
The participants had great respect for themselves in menopause. “Previously I did not care about myself and I devoted my life to my husband and children, no time to myself…. my glory consisted in the happiness of my children... that is their happiness gave me satisfaction. But reaching aging and going through menopause I wondered what about myself. Now I take time for myself. I'm more careful about my health” (Participant 1). Threat
In this study, Threat was defined as the women's negative experiences of menopause. Threat was referred to as undesirable changes and causing of concern. Five categories of this sub-theme were loss of femininity, feel aging, Emotional insecurity, Change of body image, and turmoil. Loss of femininity
Some of the participants were concerned about reproductive status and libido. “I am still single but have gone through menopause. I feel no hope for my marriage Because those men who marry should be willing to have children and I am aware that I will not be fertile and lost my femininity. My libido has decreased since menopause “(Participant 4).
Feel aging
Some women expressed menopause with a feeling of aging.”Menopause means that you are old…. your life is going downfall... I am worried about aging and fear of failure. I am afraid of ability “(Participant 7).
Emotional insecurity
The participants were upset about going through a state of divorce and so felt insecure. “People in our society misinterpret menopausal woman... as if her expire date has passed ... a worthless person. It makes me sad…feel unwanted. Our relationships have cooled off now. I am afraid of divorce “(Participant 13).
Some of the participants were concerned about their face and skin. “I was very sharply. But my body changed and my belly grew... I'm fatter than before. When you get older decline in fitness shows itself. Collagen of skin is affected. Every morning in the mirror there you see no freshness and vitality in your skin “(Participant 5).
Turmoil
Some participants, especially in the early stages of menopause were distortion and inner turmoil. "With the onset of menopause, I had severe hot flashes. I felt frustration, disturbedand anxiety... Lossmy control over the issues. I wanted to heaven and earth to get control again…”(Participant 9).
DISCUSSION
This study designed and performed with the aim of understanding the experience of menopause among Iranian women. It identified ten categories, two subthemes and one theme “Paradoxical experiences”. The study provides new insight into what is the meaning of menopause among Iranian women? How do they perceive the menopause? Most of the participants of our study referred to menopause as a natural life phase. "Natural" was defined as an inevitable but difficult time that one should go through. According to the feminist paradigm menopause is viewed as a natural developmental process that signals a life transition [19]. In Biri et al.'s study, 75.4% of the study population have had no concerns about menopause and the authors suggested that this was because of the women's understanding of menopause as a natural phenomenon, as is often the case with women from East Asian societies [23]. This means that the experiences were associated with social context, intensity and origin of each society [24]. In addition, the participants experienced menopause two sides of the same coin. Findings of a study by Mackay (2012) to explore the lived experience of the women with type 1 diabetes during the menopause suggested two themes (negative meaning and positive meaning). Negative meaning divided into 4
categories of aging, depression, fear and treating Symptoms.Positive meaning divided into 3 main categories of education, self-care and coping [25].On the other hand, in a qualitative study on the conception of the menopause two themes were identified including: physiological changes and pathological changes experiences. Physiological changes included one subtheme (entering a new phase of life as a "change"). The pathological changes categories were divided into 5 subthemes: hormonal changes, menstruation ending, loss of femininity, feel aging, producing estrogen [26]. Our findings showed that some of the participants experienced Opportunity in menopause. Opportunitywas referred to desirable changes. Opportunity was related to wisdom development, Interpersonal support, Eagerness to learn, peace of mind and self -attention.
In our study, menopause period was a time for wisdom development. It was characterized by logical thinking. The nature of their thoughts changes created the ability to evaluate issues from multiple perspectives providing deeper understanding for problem analyzing. In some studies, menopause was defined as the middle age maturity [19, 27]. In a study designed to explore Turkish women's views of menopause, maturity was defined as the wisdom of being older, being able to help youngsters and even the beginning of a new life. Similar positive meanings have been documented in some other studies from different countries [28, 29].
expressed their feelings about the need for support and understanding from those around them [19]. In our study, for some participants, menopause period was a time for training. So they strived to improve their knowledge and skills by participating in relevant programs to refine their life. Eagerness to learn were included learning resumption, training and addressing previous interests. This phase of life kept the women motivated to deal again with their previous interests and continued to benefit from learning opportunities. In another studies menopausal women strived to learn about controlling the symptoms of menopause [6, 7, 32, 33].
The participants mentioned the peace of mind to perform religious rituals resulted from ending bleeding (menstrual cessation) and feeling clean during menopause Majority of the participants referred to cleanness as “freedom”. This association between not having periods and cleanliness may be a reflection of Islamic traditions [34,35], according to which women are not allowed to participate in any religious activity during the menstrual period. It is essential to be clean and free of any fecal, urine material and blood for praying, worship and go to pilgrimage to the holy places in Islam [18, 19]. So, menopausal women's peace of mind about cleanliness for praying and worship were expected. The findings of Dabirian et al.'s study showed patients with ostomy were worried about their religious rituals, which had been disrupted by colostomy complications [36]. In another studies in Islamic countries to explore the experiences of menopausal women, the theme, "relieving", (being clean, no being comfortable to worship) were consistent with the findings of our study about positive experiences of the women in menopause [37, 38] .
In our study, the participants’ statements showed their fully appreciate their aging and going through menopause. It was self- attention that was a reflection of valuing and evaluating. Menopause helped the participants reflected on their life experiences as well as changing life style and self-
care. In other study, people with chronic illness lose part of their identity and given the social context followed by feeling of being undervalued and low attention [39]. In this study we concluded that the reason of inconsistency between findings of our study and other studies was that the participants considered menopause as a natural life phenomenon. In a qualitative study, the women of north India described menopause as a natural life phenomenon. They felt more value and played a deeper role in the family and social [40]. Our findings showed that, some of the participants experienced threat in menopause. Threat referred to negative experience. Threat was referred to as undesirable changes and causing of concern. Threat was related to loss of femininity, feel aging, emotional insecurity, change of body image, and turmoil.
beauty in which the most important concern mentioned was men’s own sexual life [42]. In a qualitative study, the most of the menopausal women talked about sexual dysfunction, they did not nominate it as a major problem. It can be said that cultural values and health beliefs influence perception of sexuality at the time of menopause [19].
Our findings showed that some the women considered menopause with a feeling of aging, ending and onset of inability. There are very limited facilities and social services for elders in Iran [18]. So, they were afraid of inability and future of elderly. Regarding the out-of-pocket payment in Iran health system [43,44] and fading of close ties between family members in recent decades, women are afraid of inability and a future that nobody can take care of them Similar findings have been documented in other studies from different countries, i.e. some menopausal women were concerned about elderliness [18, 19, 26]. In a study aimed to identify correlations of the knowledge, attitude, symptoms and management towards menopause in employed middle-aged (40-59 year old) women it was showed that women in menopause experience physical decline (feel aging, Anxiety, Exhaustion) [26]. Contradictory findings have been documented in other studies i.e. some menopausal women were accepted aging as a part of life [45]. A sense of insecurity, Emotional insecurity, was another feature of threat. Some participants felt menopause had been affected their position in their family. They were upset about going through a state of emotional divorce and then legal divorce and so felt insecure. Emotional insecurity in women during menopause encompasses individual, family and social aspects. It is a common perception that divorce, especially when it occurs in middle age, is initiated by a male partner [46, 47]. Qualitative studies on the women with vulvar pain revealed the subjects’ concerns included fear of losing femininity, threat of the feminine identity and lack of diagnosis. However, their major concerns was feeling of insecurity due
to shortcoming of marital sexual relationships andfear of divorce resulting from decreased libido and pain during intercourse [48] that was consistent with the notions of this study. However, in our study, pain during intercourse was not expressed by the participants.
In our study, the participants expressed physical dysfunctions and appearance change; some of them feeling weakness their skin and physical loss. There are many factors that lead to a person’s body image, some of these include: family dynamics, mental illness, biological predispositions (menopause, aging), and cultural expectations [49]. In Iran, most of women are concerned about change of body in menopause stage [18, 50]. Evaluating the lived experiences of the postmenopausal women in Iran aiming to explore the psycho- emotional challenges during menopause showed a cognitive style that included: change in self-image, negative reaction to this stage of life, feeling of aging and being unprepared for menopause [51]. Similar findings have been documented in other studies from different countries, i.e. some menopausal women were experienced menopause as a threat for appearance change , and others believed that change of body is not related to the menopause rather is a normal part of life [26].
In the vast majority of the participants physiological changes due to hot flashes led to psychological changes including; lack of self -control, turmoil and sense of frustration.Hot flashes are the most common symptom of menopause [52]. The influence of endocrine function on mood swing of menopausal women needs to be researched [29]. Probably, psychological factors, lifestyle, body image, interpersonal relationships, role, and socio-cultural factors affect mood swing in menopausal women [49].In a qualitative study, some women thought they should seek help if they experience a swinging temper because it seemed so intolerable, drop in motivation and depression [53].
the nature of the study limits the ability to generalize the results. However, as with all qualitative studies, results are not intended to be generalized. Nevertheless, we used maximum variation in sampling. It is possible that the findings of this study may be transferable to other Iranian women from Muslim backgrounds reside. Conclusion
Generally, demystification of meanings derived from the social context for experiences of menopause are unique in every community and every individual. In our study, the perception of menopause was said to be a natural phase which was characterized by paradoxical experiences. These data can assist healthcare providers to provide culturally competent health care to midlife Iranian women. Appropriate interventions may be helpful to facilitate connections between midlife women, increase self-awareness, assist women to manage their symptoms appropriately through self-care measures and healthcare interventions. Competing interests
None of the authors have any conflict of interest to report.
Authors, contributions
MY was involved in conceptualization, design, data analysis/interpretation, critical revision and final approval. RN was involved in design, data acquisition, data analysis/interpretation, drafting/critical revision and final approval.ZBM design, data acquisition, data analysis/ interpretation, critical revision and final approval. Acknowledgement
This project was granted by the Tehran University of Medical Sciences. The authors declare that there is no conflict of interests. The authors wish to express their sincere gratitude to the study participants without whom this study could not have been conducted.
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Table 1:Characteristics of participants
No. Age Marital status Education Number of
Children
Economic status
Employment status
1 54 Married BS/BA 2 Good Retired
2 59 Divorced Secondary
education 2 moderate Employed
3 51 Single Secondary
education 0 moderate Employed
4 54 Single BS/BA 0 Good Employed
5 57 Widowed Elementary
education 3 weak Housewife
6 56 Divorced Associate degree 4 moderate Housewife
7 50 Divorced Elementary
education 2 weak Housewife
8 53 Widowed High school
3 moderate Retired
9 54 Married Associate degree 5 Good Housewife
10 54 Married BS/BA 3 Good Retired
11 59 Married Elementary
education 2 moderate Housewife
12 48 Single High school 0 Good Employed
13 52 Married Associate degree 4 moderate Retired
14 50 Married BS/BA 3 Good Retired
15 50 Widowed Secondary
education 1 Good Housewife
16 54 Divorced Elementary
education 3 weak Housewife
17 55 Single Elementary
education 0 weak Housewife
18 55 Widowed High school 4 moderate Retired
19 52 married Secondary
education 3 Good Housewife
Table2:Theme, Sub themes, Categories
Theme Sub themes Categories
Paradoxical experiences
Opportunity
wisdom development Interpersonal support Eagerness to learn Peace of mind Self –attention
Threat
Loss of femininity Feel aging
