Revist a de Saúde Pública
I SSN 0034- 8910 versão im pressaRev Saúde Pública 2003; 37(6)
Clim acteric syndrom e: a population- based study in Braz il
Adriana Orcesi Pedroa, Aarão Mendes Pint o- Net oa, Lúcia Helena Sim ões Cost a- Paiv aa, Maria José Duart e Osisb and Ellen Elizabet h Hardya
a
Depar t am ent o de Tocoginecologia da Faculdade de Ciências Médicas da Univ er sidade Est adual de Cam pinas. Cam pinas, SP, Brasil. bCent ro Mat erno I nfant il de Cam pinas ( CEMI CAMP) . Cam pinas, SP, Brasil.
ABSTRACT
Objective
To st udy t he pr ev alence of clim act er ic, ur ogenit al and sex ual sy m pt om s in a populat ion of Br azilian w om en.
Methods
Results
The m ost pr ev alent sy m pt om s w er e ner v ousness ( 82% ) , hot flushes ( 70% ) , headache ( 68% ) , irrit abilit y ( 67% ) and sweat ing ( 59% ) . Hot flushes, sweat ing and insom nia were significant ly m ore pr ev alent in t he per i and post m eno pausal phases. The fr equency ( sev er it y ) of v asom ot or and psy chological sy m pt om s did not v ar y accor ding t o t he m enopause phase. The pr ev alence of ur inar y incont inence w as 27.4% . Com plaint s of dy spar eunia and v aginal dr y ness w er e infr equent . Decr eased libido w as t he m ost fr equent sex ual com plaint . I t w as obser v ed t hat som e clim act er ic com plaint s w er e int er r elat ed. The fir st clust er included hot flushes and sw eat ing ( v asom ot or clust er ) . The second clust er included nervousness, depression and irrit abilit y ( psyc hological clust er ) . The t hir d clust er included dizziness and palpit at ion ( at y pical clust er ) .
Conclusions
Clim act eric sym pt om s in t his populat ion w ere highly prevalent and sim ilar t o t hose described in dev eloped West er n count r ies.
Keywords
Clim act eric. Men opause. Cross - sect ional st udies.
I N TRODUCTION
The m enopause is defined as t he last m enst r uat ion and t he clim act er ic as t he t r ansit ion per iod bet w een t he r epr oduct iv e and non - r epr oduct iv e phases. The clim act er ic is char act er ized by endocr ine changes due t o t he decline in ov ar ian act iv it y ; biological changes as a r esult of dim inishing fer t ilit y ; and clinical changes consequent t o t he alt er at ions in t he m enst r ual cy cle and a v ar iet y of sy m pt om s.2 5 The sy m pt om s associat ed w it h t he clim act er ic per iod hav e now been w ell docum ent ed in ot her count r ies. They affect ar ound 60 t o 80% of w om en and can occur ev en befor e t he phy siological cessat ion of t he m enst r ual cy cles.1 9 The associat ion of t he m enopause w it h such sy m pt om s w as fir st described m ore t han 200 years ago.2 3 The ex planat ion associat ed t he cessat ion of m enst r ual flow w it h physical m echanism s and relat ed an associat ion w it h vaginal at rophy and urinary sym pt om s. One of t he fir st book s about t he m enop ause report ed t hat , during t he w om an’s “ change in life” , she is fr equent ly affect ed by cancer , r heum at ism and in som e cases by a “ v er y localized ner v ous affect ion” .
obj ect iv e of ascer t aining t he pr ev alence of clim act er ic, ur ogenit al and sex ual sy m pt om s am ong wom en in Brazil.
M ET HODS
A descr ipt iv e, ex plor at or y cr oss- sect ional st udy of populat ion sur v ey t y pe w as per for m ed. The t ar get populat ion consider ed for t he sam ple size calculat ion w as t he fem ale nat ive Br azilian populat ion aged 45 t o 60 y ear s t hat w as r esident in Cam pinas, St at e of São Paulo, in t he y ear 1997. The calculat ed m inim um num ber of interv iew s w as 367 w om en, w hich w as incr eased by 20% , result ing in 456 int er v iew ees, in or der t o allow for possible user s of hor m one r eplacem ent t her apy . The select ion of t he subj ect s w as done by m eans of conglom er at es and t he r efer ence ut ilized as t he sm allest sam pling unit w as t he census sect or , as defined by t he I nst it ut o Br asileir o de Geogr afia e Est at íst ica ( Br azilian I nst it ut e of Geogr aphy and St at ist ics) . Census sect or s gener ally consist of sev er al block s but in som e cases con sist of on e sh an t y t ow n (favela ) . St udy w as m ade of 82 census sect or s dr aw n by lot s fr om am ong all t he 845 sect ors in Cam pinas. I n each of t he sect ors, a m inim um of one and m axim um of six w om en w er e chosen. Those t hat par t icipat ed in t he st udy w er e ident ified by m eans of an int er v iew in t heir hom es. To m ake a r andom select ion of t he w om en, a spacing of six addr esses bet w een t he houses at w hich t he int er v iew er s w er e t o obt ain infor m at ion on t he w om en liv ing t her e w as adopt ed. For t he select ed w om en w ho agr eed t o par t icipat e in t he st udy , t he int er v iew er r ead t he St at em ent of Fr ee and I nfor m ed Consent , com piled in accor dance w it h Resolut ion 196/ 96 of t he Nat ional Healt h Council.
Dat a collect ion w as begun on Oct ober 14, 1997, and concluded on Januar y 15, 1998, t hus t ot aling 73 day s of fieldw or k . I n t ot al, 12,238 addr esses w er e list ed, of w hich 2,805 w er e dr aw n by lot s and appr oached. Of t hese addr esses, 1,771 w er e r esident ial and 1,034 non- resident ial. I n 57% ( 1008/ 1771) of t he r esident ial addr esses, it w as ascer t ained t hat no w om en w it hin t he age gr oup t o be st udied w er e living t her e. I n 11% ( 192/ 1771) of t he r esident ial addr esses dr aw n by lot s, t he int er v iew er s w er e unable t o find out w het her t her e w er e any r esident s eligible for t he st udy , eit her because t he r esident s r efused t o giv e t he infor m at ion or because nobody w as ev er found w ho could giv e t his infor m at ion. Of t he 571 eligible w om en cont act ed, t he int er v iew w as not held in 51 cases ( 9% ) because of difficult y in ar r anging a m or e appr opr iat e occasion. I n 64 cases ( 11.2% ) , t he w om an con t act ed r efused t o par t icipat e in t he st udy . Gener ally , t her e w as good r ecept iv it y am ong t he w om en appr oached, and t he m aj or it y ex pr essed int er est in r esponding t o t he quest ions. For each w om an int erview ed , 3.8 resident ial hom es were visit ed ( 456/ 1771) . I n t he m aj or it y of t hese hom es, t he w om an liv ing t her e w as out side of t he age gr oup set for t he st udy .
A st r uct ur ed pr et est ed quest ionnair e w as ut ilized for obt aining t he infor m at ion r epor t ed by t he w om en, w hich w as dr aw n up and adapt ed by t he aut hor s fr om t wo ot her quest ionnair es. One of t hese w as supplied by t he I nt er nat ional Menopause Societ y and I nt er nat ional Healt h Foundat ion aft er being applied in seven count ries in Sout heast Asia in 1993.3 The ot her w as supplied by t he Nor t h Am er ican Menopause Societ y and w as applied in t he Unit ed St at es in 1993.2 2
The m enopausal st ages defined by Jaszm ann in 19731 0 were ut ilized. Wom en in t he prem enopausal st age had regular m enst rual cycles or a m enst rual pat t ern sim ilar t o w hat t hey had during t heir r epr oduct iv e life. Wom en in t he per im enopausal st age had m enst r ual cycles over t he last 12 m ont hs, but w it h a change in m enst r ual pat t er n in com par ison w it h ear lier pat t er ns. Wom en in t he post m enopausal st age had t heir last m enst r ual cy cle at least 12 m ont hs befor e t he int er v iew .
sym pt om s such as nervousness, irrit abilit y, headache, depression and insom nia ( psychological sym pt om s) during t he four - w eek per iod pr eceding t he st udy. The pr ecoded r esponses w er e " never " ; " less t han t hree days a m ont h" ; " four t o t en days a m ont h" and " eleven or m ore days a m ont h" . The scor ing sy st em pr oposed by t he I nt er nat ional Menopause Societ y w as ut ilized.3
To ev aluat e t he ur ological sy m pt om s, quest ions about ur inar y incont inence w er e ut ilized. These ask ed about urine losses when coughing, laughing or carrying a weight , and whet her such sym pt om s had appear ed dur ing t he t hr ee- y ear per iod pr eceding t he st udy . Cases of ur inar y incont inence t hat st ar t ed m or e t han t hr ee y ear s befor e t he st udy or aft er par t ur it ion or gy necological sur ger y w er e r egar ded as ir r elev ant t o t he obj ect iv es of t he st udy and w er e disconsider ed. Wit h r egar d t o genit al com plaint s, quest ions were asked only in relat ion t o dyspareunia and vaginal dryness, and t hese sym pt om s w ere only t ak en int o consider at ion if t hey w er e pr esent dur ing t he 12 m ont hs pr eceding t he st udy . Ot her cases, such as ear ly onset and pr ior ex ist ence w er e disconsider ed. For t he evaluat ion of sexual com plaint s, quest ions w ere asked regarding t he dim inut ion of libido, increased or decreased frequency of sex , t he feeling of unat t r act iv eness and ot her sex ual com plaint s ( open quest ion) t hat had occur r ed less t h an on e y ear bef or e t h e int erview.
The follow ing act iv it ies and st r at egies w er e under t ak en t o ensur e t he qualit y of t he dat a: t r aining of t he int er view er s and super visor ; pr epar at ion and use of t he inst r uct ion m anual for t he int er view er s; supervision and m onit oring of t he dat a c ollect ion by t he super v isor and head r esear cher ; v er ificat ion t hat t he int er v iew w as com plet ely and fait hfully fulfilled; r epet it ion of t he applicat ion of sect ions of t he quest ionnair e by t he super v isor . The int er v iew er s r eceiv ed specific t r aining for t he applicat ion of t he “ St at em ent of Consent ” and t he et hical concept s for r esear ch inv olv ing hum an beings.
For t he dat a analy sis, t he pack age " St at ist ical Pack age For Social Sciences" for Per sonal Com put er ( SPSS - PC) w as ut ilized. The chi- squ ar ed t est in con t ingency t ables w as ut ilized in t he dat a analy sis. The lev el of st at ist ical significance consider ed w as 0 . 0 5 . Since t he obj ect iv e of t his st udy w as t o analy ze t he nat ur al clim act er ic, w om en using hor m onal cont r acept iv es or hor m one r eplacem ent t h er apy w er e excluded fr om t he analy sis of t he v asom ot or and psy chological signs, because t hese m edicat ions could have m asked t he clim act eric sym pt om s.
For analy zing t he pr ev alence of t he clim act er ic sy m pt om s, t hey w er e fir st classified as pr esent or absen t . To f ocu s m ore on t he sev er it y of t he sy m pt om s, t he cir culat or y index w as adopt ed. This ex pr esses av er age v alues for t he fr equency of each of t he v asom ot or sy m pt om s ( hot flushes, sw eat ing, palpit at ion, dizziness) suffer ed by t he w om en in t he sam ple. This index obt ained by sim ple addit ion of t he fr equency scor es indicat ed by t he w om en, w it h t he scor e for each sy m pt om r anging from one, for " never" , t o four, for " eleven or m ore t im es a day" . The psychological index w as ut ilized sim ilar ly, on t he basis of t he psychological com plaint s ( ner v ousness, ir r it abilit y , headache, depr ession and insom nia) , also w it h scor ing r anging fr om one t o four . These indices have been st andar dized and ut ilized by t he I nt er nat ional Menopause Societ y and I nt er nat ional Healt h Foundat ion.3 The differen ces bet w een t he av er ages of t hese indices for t he t hr ee m enopausal st age gr oups w er e ev aluat ed using Kruskal- Wallis v ar iance analy sis.
The pr ot ocol for t he pr esent st udy w as assessed and appr ov ed by t he Resear ch Com m ission of t he Depar t m ent of Obst et r ics and Gy necology and t he Resear ch Et hics Com m it t ee of t he Facult y of Medical Sciences of Univ er sidade Est adual de Cam pinas.
RESULT S
The sy m pt om at ology associat ed w it h t he clim act er ic sy ndr om e w as highly pr ev alent , w it h ar ound 96.9% of t he w om en ex per iencing at least one of t he sy m pt om s. For t his pr ev alence analy sis, 88 w om en ( 1 9 . 3 % ) w h o w er e at t h at tim e using horm one replacem ent t herapy and one wom an using or al hor m onal cont r acept iv es w er e ex cluded. The st at ist ical com par ison w as done in accor dance w it h t he m enopausal st age. Am ong t he v asom ot or sy m pt om s, t he m ost pr ev alent w er e hot flushes, dizziness and sw eat ing. Hot flushes and sw eat ing w er e significant ly m or e fr equent am ong w om en in t he per i and post m enopausal st ages ( Table 1) .
Table 1 – Percentage distribution of the prevalence of vasomotor symptoms, according to the menopausal stage. (N=367)*
Symptom Menopausal stage
Pre Peri Post p** Total Hot flushes 50.5 77.9 77.8 <0.01 70.3 Dizziness 54.5 61.8 61.1 0,49 59.4 Sweating 46.5 57.4 66.2 <0.01 59.1 Palpitation 42.6 52.9 53.5 0.18 50.4
Total (N) 101 68 198 367
*Excluding 89 women, of whom 88 were using hormone replacement therapy and one was using oral hormonal contraceptives.
**Chi-squared.
Am ong t he psy chological sy m pt om s, t he m ost fr equent w er e ner v ousness, headache and ir r it abilit y . The pr evalence of t hese sym pt om s w as high and sim ilar in t he t hr ee gr oups, independent of t he m enopausal st age, w it h t he except ion of insom nia, w hich w as significant ly m or e fr equent am ong w om en in t he per i and post m enopausal st ages ( Table 2) .
Table 2 – Percentage distribution of the prevalence of psychological symptoms, according to the
menopausal stage. (N=367)*
Symptom Menopausal stage
Pre Peri Post p** Total Nervousness 79.2 89.7 80.3 0.16 81.7 Headache 76.2 72.1 63.1 0.05 68.4 Irritability 67.3 70.6 66.2 0.79 67.3 Depression 55.4 67.6 57.6 0.24 58.9 Insomnia 40.6 55.9 61.1 <0.01 54.5
Total (N) 101 68 198 367
**Chi-squared.
The r ange possible for t he cir culat or y index w as 4 t o 1 6 . Table 3 show s t hat t he sev er it y of t he vasom ot or sym pt om s w as low . The highest scor e obser ved w as 6.85, am ong w om en in t he per im enopausal st age. The sev er it y of psy chological com plaint s w as equally low , consider ing t hat t he r ange possible for t he psy chological index w as 5 t o 20. The highest psy chological index obser v ed w as 10.99, am ong w om en in t he per im enopausal st age. The sev er it y of t he v asom ot or and psy chological calculat ed by m eans of t he cir culat or y and psy chological indices did not giv e ev idence of significant differ ence accor ding t o t he m enopausal st age. I n ot her w or ds, once t he sy m pt om w as pr esent , it s sev er it y did not alt er w it h t he m enopausal st age ( Table 3) .
Table 3 – Average values of the “circulatory index” and “psychological index”, according to the menopausal stage. (N=367)*
Indices Menopausal stage
Pre Peri Post p**
Circulatory index 6.26 (±2.15) 6.85 (±2.09) 6.54 (±2.41) 0.22 Psychological index 10.35
(±3.75)
10.99 (±4.02)
10.36 (±4.06)
0.52
Total number (N) 101 68 198
*Excluding 89 women, of whom 88 were using hormone replacement therapy and one was using oral hormonal contraceptives.
**Non-parametric Kruskal-Wallis test.
The aim w as t o ev aluat e only t he ur ogenit al sy m pt om s associat ed w it h t he clim act er ic. Thus, ur inar y incont inence t hat began m or e t han t hr ee y ear s pr ev iously and/ or w as t he r esult of par t ur it ion or gy necological sur ger y w as not consider ed. The fr equency of ur inar y incont inence r elat ed t o t he clim act eric period w as approxim at ely 27.4% , and w as m ore prevalent am ong w om en in t he pre and perim enopausal periods. Com plaint s of dyspareunia and vaginal dryness were infrequent , alt hough m or e pr evalent in t he post m enopausal per iod ( Table 4) .
Table 4 – Percentage distribution of the prevalence of urogenital symptoms, according to the menopausal stage. (N=456)
Urogenital symptoms Menopausal stage
Pre Peri Post Total (%) p* Urinary incontinence 28.2 41.3 22.8 27.4 0.02
Dyspareunia 0.8 1.2 2.3 1.8 NA
Vaginal dryness - 1.2 1.5 1.1 NA
Total number 117 80 259 456
*Chi-squared test.
Wit h regard t o sexual com plaint s, dim inished libido was t he m ost frequent , and t his predom inat ed in t he per i and post m enopausal st ages. An act iv e sex life w as r epor t ed by 66.4% of t he w om en and, of t h o se who w er e inact iv e, t he m ain r eason w as t he lack of a par t ner ( 63.4% ) or illness of t he par t ner ( 11.7% ) . Dy spar eunia or t he fear of get t ing pr egnant did not const it ut e r easons for sex ual abst inence, and t he av er age fr equency of sex ual int er cour se w as six t im es a m ont h. Am ong t he wom en wit h an act ive sex life, around 86.2% report ed orgasm ic sexual int ercourse.
Fr om t he analysis of t he m ain com ponent s, consider ing nine var iables indicat ive of t he sy m pt om at ology of t he clim act er ic and ur inar y incont inence, t hr ee f act or s w er e ex t r act ed. Th e cor r elat ion bet w een t he var ious sym pt om s of t he clim act er ic syndr om e ar e r epr esent ed gr aphically in t he Figure.
Figure – Analysis of the main components of the interrelationships between climacteric symptoms.
Th e t h r ee f act or s ident ified in t he analy sis of t he m ain com ponent s ex plain a t ot al of 54.5% of t he v ar iance obser v ed. I t w as seen t hat som e clim act er ic com plaint s ar e int er r elat ed. The fir st fact or included t he hot flushes and sw eat ing ( vasom ot or agglom er at ion) ; t he sec ond included depression, nervousness and irrit abilit y ( psychological agglom erat ion) ; and t he t hird included dizziness and palpit at ion ( at y pical agglom er at ion) . The ot her sy m pt om s ar e at a r elat iv ely lar ge dist ance on t he gr aph and appear t o hav e lit t le int errelat ionship w it h t he ot her sym pt om s, as can be verified in r elat ion t o headache and ur inar y incont inence. I nsom nia w as m or e int er r elat ed w it h t he agglom er at ion of v asom ot or sy m pt om s t han w it h t hat of t he psy chological sy m pt om s.
Th e pr ev alen ce of clim act er ic sy m pt om s lik e hot flushes, sw eat ing, palpit at ion, dizziness, anx iet y , ir r it abilit y, headache, depr ession and insom nia w as ver y high in t he populat ion st udied, t hus confir m ing t hat t he clim act er ic t r ansit ion has a lar ge im pact on t he liv es of t hese w om en. This is sim ilar t o what has been report ed am ong wom en in developed West ern count ries. For exam ple, sym pt om s have been report ed in 85% in Holland,1 7 55% in England,8 77% in Aust ralia1 and 74% in t h e Un it ed St at es.1 5
I n sout heast Asian count r ies, t he pr evalence of vasom ot or sym pt om s has been found t o r ange fr om 8.3 t o 48.9%3 and has been report ed in 82% of Tanzanian w om en.1 4 I n Pak ist an, such com plaint s hav e been found t o r ange fr om 7 t o 57% , depending on t he econom ic class.2 4 I n t he Unit ed Ara b Em ir at es t his pr evalence w as 45% .1 8 I n Japan, only 9.7% of w om en report ed hot flushes during t he clim act er ic.1 3
I n t he indexed m edical lit erat ure, no populat ion- based st udies on t he pr ev alence of clim act er ic sym pt om s in Lat in Am erican populat ions were id ent ified. Only som e st udies on hospit al populat ions w ere seen, in w hich t he prevalence of t hese sym pt om s w as high and in t he range of 74.6 t o 97% .6 Leidy ( 1998)1 2 m ade a com par ison bet w een t w o populat ion gr oups, one hospit alized and t he ot her w it hin t he gener al populat ion, and found no differ ence in t he pr ev alence of sy m pt om s. The only differ ences obser v ed in t hat st udy w er e in r elat ion t o t he use of hor m one r eplacem ent t her apy ( 52% v s. 20% ) and t he num ber of hy st er ect om ies, w hich, as w ould be ex pect ed, pr edom inat ed in t he hospit alized populat ion. I n t he pr esent st udy , hot flushes occur r ed in ar ound 50.5% of t he w om en in t he pr em enopausal st age. I t w as seen t hat pr ev ious st udies, bot h of cr oss- sect ional and longit udinal t y pes, also gav e ev idence of t he pr esence of hot flushes in 15 t o 25% of t he w om en w ho w er e st ill m enst ruat ing regularly.8 , 9 Oldenhave et al ( 1993)1 7 found a pr ev alence of hot flushes am ong prem enopausal w om en aged over 39 years of around 41.1% . The explanat ion for t his is unclear. I t is possible t hat a definit ion of t he m enopausal st age based only on t he m enst r ual pat t er n m ay not adequat ely char act er ize w om en w ho ar e in t he per im enopausal st age but ar e st ill m enst r uat ing regularly.
I t m ay be t hat wom en who are m enst ruat ing regularly and report hot flushes hav e follicle- st im ulat ing hor m one lev els t hat ar e higher t han in w om en w ho do not ex per ience hot flushes, w hile t he est r adiol lev el r em ains unalt er ed. The m enst r ual cr it er ion adopt ed in t he pr esent st udy w as t he sam e as is com m only used, but t here are som e considerable problem s wit h t his definit ion of t he m enopausal st age. Anot her explanat ion for t his phenom enon is t hat som e w om en have t em per at ur e r egulat ion sy st em s t hat ar e less st able or m or e sensit iv e t o such changes and t her efor e t hey ar e mor e suscept ible t o exper iencing sym pt om s dur ing t he clim act er ic.2 0 The w om en st udied w er e in t he age gr oup of gr eat er t han or equal t o 45 y ear s old, but it is k now n t hat clim act er ic sy m pt om s can alr eady be felt fr om t he age of 40 y ear s, or in ot her w or ds, som e y ear s befor e t he cessat ion of m enst r uat ion.
Wom en w ho hav e pr em enst r ual t ension m ay dev elop som e r eact ions and ar e m or e sensit iv e t o t he m enst r ual pr ocess, and t her efor e t hey ant icipat e som e sy m pt om s w hen t her e ar e changes in t heir m enst rual pat t ern. Ther e is som e hor m onal v ulner abilit y in t hese w om en t hat can cause bot h prem enst rual sym pt om s and vasom ot or sym pt om s. I t is also possible t hat vasom ot or sym pt om s are m ore com m on am ong wom en who suffer from depression before t he m enopause.4 I n t h e pr esen t st udy , a pr ev alence of depr ession in t he pr em enopausal st age of ar ound 55.4% w as found.
Accor ding t o t he consensus on t he “ Clim act er ic Sy ndr om e” ,2 1 hot flushes, sw eat ing and at r ophic v aginit is ar e t he only sy m pt om s char act er ized as r esult ant fr om hy poest r ogenism . A differ ent ex planat ion should be giv en t o ot her sy m pt om s t hat ar e usually at t r ibut ed t o est r ogen deficiency or list ed as par t of t he clim act er ic sy ndr om e. I f, on t he one hand, v asom ot or sy m pt om s ar e associat ed w it h t he dev elopm ent of t he m enopause, on t he ot her hand psy chological sy m pt om s ar e unconnect ed w it h t he m enopausal st age. I n t he pr esent populat ion st udied, a high pr ev alence of psy chological sy m pt om s w as obser v ed, but neit her t he pr ev alence nor it s sev er it y could be cor r elat ed w it h t he m enopausal st age.
The obser v at ion t hat psy chological and v asom ot or sy m pt om s ar e agglom er at ed separ at ely suggest s t hat t hey hav e differ ent et iological m echanism s. Ther e is st r ong ev idence t hat v asom ot or sy m pt om s ar e a r eflect ion of hor m onal changes, w hile som e psy chological sy m pt om s can be at t r ibut ed t o hor m onal alt er at ions or social fact or s t hat coincide w it h t he m enopause. The r esult s fr om t his st udy coincide w it h r esult s fr om pr ev ious st udies, w it h t he pr ev alence of psy chological sym pt om s depending m or e on t he psy chosocial pr ocess or t he aging t hat t ak e place concom it ant ly w it h t he endocr ine pr ocess.7 Ther e ar e now st udies giv ing ev idence t hat depr ession, anx iet y , ir r it abilit y and headache ar e no m ore frequent in t he peri and post m enopausal st ages t han in any ot her per iod of t he w om an’s life. One of t he fact or s t hat pr edict t he occur r ence of t hese psy chological sy m pt om s dur ing t he clim act er ic is t he hist or y of pr em enst r ual t ension. Nov aes et al ( 1998)1 6 highlight ed t hat one of t he f act or s t h at could pr edict t he occur r ence of psy chological sy m pt om s dur ing t he clim act er ic is pr ev ious prem enst rual t ension.
I nsom nia is fr equent ly at t r ibut ed t o hot flushes, but m ay also be associat ed w it h psy chological sym pt om s, w hich w ould be a r eflec t ion of it s associat ion w it h depr ession. I n t he pr esent st udy , insom nia w as r elat ed t o bot h t he v asom ot or and t he psy chological sy m pt om s, alt hough a closer associat ion w as obser v ed w it h t he v asom ot or sy m pt om s, pr obably r esult ing fr om t he classic cascade of sym pt om s: hot flushes and sw eat ing at night gener at ing insom nia and, consequent ly, ir r it abilit y and fat igue on t he follow ing day .
I t w as seen in t his st udy t hat urinary incont inence is a frequent com plaint am ong w om en during t he clim act er ic per iod. This sy m pt om has ear ly occur r ence, giv en t hat one- t hird of t he w om en in t he prem enopausal st age and approxim at ely half of t he wom en in t he perim enopausal st age m ent ioned it , in cont r ast t o t he w om en in t he post m enopausal st age, am ong w hom only one- quart er m ent io ned urinary incont inence. This finding is in agreem ent w it h a st udy perform ed in Sout heast Asia, in w hich t his t ype of com plaint w as m ost fr equent am ong w om en in t he per im enopausal st age.3 I n cont r ast , it has been obser v ed in West er n count r ies t hat it appear s lat er , i.e. in t he post m enopausal st age. On t he ot her hand, it is possible t hat no differ ences w ill be obser v ed in t he ur inar y incont inence pr ev alence r at es bet w een pr e and post m enopausal w om en. Ov er all, it w as obser v ed t hat 27.4% of t he w om en in t he age gr oup st udied pr esent ed ur inar y incont inence upon exer t ion.
I t is k now n t hat w om en liv ing t oget her w it h a par t ner pr esent gr eat er pr ev alence of genit al com plaint s t hat t hose t hat do not hav e a par t ner . This m ight be ex plained by t he gr eat er per cept ion of t he low er genit al t r act am ong w om en w ho, because t hey hav e a par t ner , consequent ly w ould hav e gr eat er sex ual act iv it y . How e v er , w it h adv ancing age, t her e could also be a gr adual loss of libido, t her eby r esult ing in dim inishing sex ual act iv it y , w hich w ould r educe t he per cept ion of at r ophy of t he vaginal epit helium .5
Appr ox im at ely 30% of t he w om en st udied r epor t ed t hat t her e had been som e change in t heir sex life over t he pr eceding 12 m ont hs. Of t hese, ar ound 22% r epor t ed dim inished libido, independent of t he m enopausal st age. Despit e t he dim inished libido, t he frequency of sexual int ercourse had not changed. Ut ian et al ( 1994)2 2 also r epor t ed t hat 31% of clim act er ic w om en in t he Unit ed St at es had a change in t heir sex life. The m ain com plaint s were dim inished libido ( 62% ) , vaginal dryness ( 55% ) and dyspareunia ( 32% ) . Despit e t his, only 30% of t he wom en report ed dim inished frequen cy o f sex ual int er cour se. Mult iple fact or s affect sex ual ex pr ession and t he r elat iv e cont r ibut ions of t he int er act ions bet w een hor m onal and psy chosocial det er m inant s and t he aging it self ar e not clear ly delineat ed.2
I t is believ ed t hat t he infor m at ion coming fr om t he pr esent st udy m ay ser ve as a m ot ivat ion for healt hcar e pr ov ider s t o dir ect r esour ces int o t he field of infor m at ion for w om en and t he set t ing up of clim act er ic at t endance ser v ices focused on t he r ealit ies of w om en in Br azil, in an at t em pt t o c or r espond t o t heir ex pect at ions and needs. I t m ust be r ecor ded t hat no sim ilar st udy has been found in t he nat ional and int er nat ional lit er at ur e, w hich suggest s a need for fur t her r esear ch on t his t opic.
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