Social Determinants of Health in Menopause: An Integrative Review

Introduction

According to the World Health Organization, health is defined as a state of complete physical, mental, and social welfare, and not merely the lack of disease or infirmity. Today, global health systems draw their plans based on family and women’s health.¹ The aging period of women is associated with a natural occurrence called menopause; its principal characteristic is a disability to fertility and reproduction. Menopause, which means full stop of menstruation due to the lack of estrogen production from ovaries, is considered as a natural occurrence in women’s lives.² Most women experience menopause at the age of 45 to 54 years old. Still, the average age of menopause is the age of 51. Researches have indicated the same results in Iran. Researchers estimate by the year 2030, 1.2 billion people will be around at the menopausal and postmenopausal age.³ By the year 2022, about 5 million women will be at menopausal age in Iran.² Because of increasing life expectancy, women are expected to spend on average one third of their life in postmenopausal period.⁴ Major issues of menopausal age are physical, psychological and sexual problems, including vasomotor symptoms (hot flashes and night sweats), vaginal dryness and dyspareunia, urogenital atrophy, depression, tensions, headache, insomnia, lack of energy, fluid retention, back pain, difficulty in concentration, confusion, and cognitive decline.^5,6 The main reason for menopausal symptoms is the reduction of estrogen in the ovaries.⁷

As stated by World Health Organization, SDH (social determinants of health) defined as “situations in which people are born, nurture, work, live, and the broader set of forces and systems determining the conditions of daily life.” These forces and systems include economic plans and policies, development programs, social standards, social strategies, and political structures.⁸ Menopause is a complex phenomenon that involves physical, psychological, and social changes in life. On the other hand, the experience of menopause is influenced by cultural norms, social factors, and personal knowledge about menopause.⁹ Although women experience similar symptoms in menopause due to hormonal changes, but additional factors include age at menopause, education, employment, individual and cultural differences, health status, type of menopause (natural or surgical), stress, environmental conditions and social communications effect on menopausal experiences.¹⁰ Thus, the aim of present integrative review is to identify social determinants of health in menopause.

Materials and Methods

An integrative review was conducted using the guide published by the University of York (Center for Reviews and Dissemination, University of York).¹¹ In the present Study; we managed to find social determinants of health in menopause using terms shown in Table 1.

Table 1 Combination of Words Used to Search Articles

The following databases were searched for relevant literature: MEDLINE, ISI Web of Knowledge, Scopus, Google Scholar, and the Iranian Info Net (IranDoc, IranMedex, MagIran, and SID) from January 1990 to Jan 2019. The following criteria were used to decide which articles to be included:

1. Document type: article;
2. Language: English and Persian;
3. Study design: quantitative and qualitative;
4. Existing essential keywords in title or abstract

Articles were excluded if they were not in English or Persian and if the full-text was not available.

Two authors were asked to read the title and abstract of the studies obtained and to read the full texts finally to decide which articles had met the criteria to be included in the present integrative review. The variables of interest were the first author’s name, year, country, study design, and study results. The two authors negotiated any disagreements to achieve agreement.

In order to evaluate articles, the STROBE tool (Strengthening the Reporting of Observation Studies in Epidemiology) and the COREQ tool (Consolidated Criteria for Reporting Qualitative Research) were used.

Overall, 3050 studies were extracted. After removing repeated studies (n=250), the remaining 2800 articles were assessed, and an additional 1050 irrelevant studies were excluded. Of the remaining 1750 papers, 1710 articles were also removed because they were not eligible, and eventually, 40 full-text articles were included in the analysis (Figure 1). Table 2 shows the articles we covered in the present study.

Table 2 Studies on Social Determinants of Health in Menopause

Figure 1 Flowchart of study selection progress.

Results

Cultural Factors

The attitude toward menopause is influenced by the culture and beliefs of the community.^12–14 In Western culture, negative words like “fertility failure” or “ovarian failure” are used for menopause, which means that menopause is a condition that requires treatment, not a normal transition period in women’s lives. Western countries that do not necessarily place high importance on fertility often place a high value on youthfulness. Consequently, in these societies, the menopause reflects age progression and loss of youth combined with the loss of sexual attractiveness and can lead to negative attitudes towards menopause. In Arab culture, negative words are used for “menopause,” and this reflects the negative attitude of these communities towards the phenomenon of menopause. Women in Arab culture place a high priority on fertility, and when they experience the inability to fertile as a result of menopause, describe this period as “desperate age.” The severity of menopausal symptoms is related to the attitude toward this phenomenon. Japanese menopause women report the fewest complaints of menopausal symptoms and have the lowest incidence of breast cancer and menopausal complications. Apart from the genetic factor that certainly affects this phenomenon, the role of culture should not be ignored because, in their opinion, it is a positive phenomenon. Turkish women complain more about menopause, according to more than 90% of them, menopause is a negative phenomenon. Most of these women describe this period as “the end of youth, feeling old, losing femininity, hormonal changes, and the cessation of menstruation.” Consequently, this view leads to a negative attitude toward menopause.¹⁵

Researchers found that Mayan women are considered to be respected as elderly when they enter menopause, taking care of their children is over. Their brides perform many of their routine tasks. In a culture where aging raises the status of a woman and menopause is considered as a sign of experience, it is natural for women to consider menopause as a time of freedom.¹⁶ Chinese women consider menopause as “rebirth,” and, in their view, they can save energy that was previously lost due to fertility and childbirth. Because of this positive attitude to menopause, the lowest amount of drugs are used for treating menopausal symptoms.¹⁷ In a study by Hunter et al (2009), Greek women did not consider menopausal symptoms unlikely to receive medical treatment. According to this research, non-European women have a better attitude toward menopause and fewer hot flashes. Also, menopause is not considered as a medical problem in many developing countries, so women pay less attention to symptoms and accept menopause as a normal part of life.¹⁶

Research shows that religion has a positive impact on menopause. The prayer, which is a kind of Islam practice, is regarded as a type of meditation. Several studies have examined the role of prayers for the acceptance of life crises such as illness, discussed the abundant and important psychological roles of religion, and argued that religion helps individuals better understand and cope with life events. In this way, Iranian women consider menopause as a natural happening and God’s predetermination. So they can cope with this challenge well regarding their religious beliefs. Also, according to Islam, prayer and sexual intercourse are forbidden during the menstrual period. Consequently, Iranian women consider menopause as a time to relieve menstrual problems, which can pray and have‏ a sexual relationship.¹⁸

The culture and attitude of individuals towards menopause can affect the severity of menopausal symptoms, with a negative attitude toward menopause exacerbates symptoms in this period.^18–20 Also positive attitude toward menopause improves the quality of life in this period.²

Lifestyle

Studies indicate that there is a relationship between lifestyle (including nutrition and body mass index) and the severity of menopausal symptoms.⁵ Sociocultural factors can affect people’s lifestyle and nutrition. In Japanese culture, the incidence of menopausal complications and cancers has declined noticeably due to increased consumption of soy and phytoestrogens, which contain isoflavones.¹³ Due to the high content of phytoestrogens in the Asian diet, the severity of menopausal symptoms is low.^15,21 Exercise reduces the severity of menopausal symptoms.^15,22–24 According to studies, the prevalence of menopausal depression among athlete women is less than others. Therefore, doing an exercise can play a useful role in decreasing depression.²⁰ Physical activity improves the quality of life by reducing the severity of vasomotor symptoms and enhancing self- imagine.^6,25

Studies show that reducing BMI (Body Mass Index) leads to early menopause. According to these studies, women with high BMI are more likely to produce endogenous estradiol and estrogen, which also causes a delay in menopause.²⁶ Although other studies report conflicting results, which show that obesity and decreased physical activity can lead to early menopause.²⁷ Obesity and overweight also reduce the quality of life at menopause, which is due to the increased prevalence of chronic diseases, negative self-imagine, and decreased physical activity in obese women.^23,25,28

Smoking can influence the age of menopause, in which smokers experience menopause at an earlier age. Some studies illustrate that smoking is the most important cause of early menopause.^27,29–31 Table 3 shows studies on the relationship between menopausal age and lifestyle/norms.

Table 3 Studies on the Relationship Between Menopausal Age and Lifestyle/Norms

Social Support

Challenges in the life of postmenopausal women make changes in their family demands. So they need more support from their families. If they do not receive support, negative attitudes include loneliness, malaise, and family problems would be developed.^18,32 Social support through emotional and informational assistant increases the ability of individuals to cope with stress and reduces psychological and physical symptoms. Studies indicate that social support has reverse and meaningful correlation with the experiences of women in menopause so that by increasing social support from different sources, physical and emotional symptoms decrease.¹⁸ Husband is the most important and closest person who can support a woman in this challenge by a correct understanding of his wife’s situation and problems.^2,33 According to the studies, emotional support of the spouses can reduce depression and anxiety and improve social relationships in menopause. Educated men are continuously looking for ways to improve their knowledge and performance about menopause, and their wives experience a higher quality of life during menopause. During menopause, men can help their wives by doing exercise with them, emotional support, teaching relaxation techniques, and spending more time with them. Therefore, improving the quality of life of women in menopause more than anything else depends on educating women and their husbands.³⁴

According to research, after implementing an educational program for husbands, the average score of social support perceived by women was higher than before, so that the difference was meaningful. In other words, when the husband has more information about her wife’s mental and physical conditions, he will be able to understand more and support her. Social support has beneficial effects on physical and mental health and prevents depression in women.³³

Education

According to research, there is a negative relationship between the level of knowledge and the severity of menopausal symptoms. That is, women with less education experience more severe symptoms, and women with higher education are more aware of menopausal symptoms and strategies to deal with it and are more likely to seek treatment for their symptoms.^{2,7,10,19,23,24,31} Also, the average age of menopause in educated women is higher than that of uneducated ones.^30,35,36 In comparison to others, educated women have better health conditions and lower morbidity. The probable reason is adopting a healthy lifestyle and making informed decisions about reproductive health by them.²⁶ Studies have indicated that educated women have a higher quality of life³⁷ and fewer sexual dysfunctions during menopause. Knowing about menopause can increase orgasm in sexual intercourse, which results in sexual satisfaction.³⁸

Husband’s education also affects the quality of life of postmenopausal women, especially in the psychosocial dimension, which may be due to a better understanding and supporting his wife.²³

Employment and Economic Situation

A growing body of research supports the notion that homemakers experience a lower quality of life and higher menopausal symptoms in compare to employed women.^19,23 Improving the financial position of women improves the quality of life in menopause, which can be due to increased access to health care services and receiving counseling to manage menopausal symptoms.^{2,23,24,28,37} Sexual satisfaction is higher in employed women, which is due to increased self-esteem because of financial independence.³⁸

It is believed that lower socio-economic condition leads to early menopause.^29,35,36 Also, people who had an unfortunate economic situation in childhood experience earlier age at menopause, which is probably due to an increase in smoking in adulthood.^39,40

Marital Status and Number of Pregnancy and Childbirth

Married women have a better general health status than single ones.^1,41 According to research, unmarried women experience more severe symptoms in menopause compared to married ones.^15,19,42 The probable reason for this is that married women have better social relationships and family supports.^23,37 Also, single women experience menopause at an earlier age compared to married and divorced women, which exposes them to complications such as the increased risk of osteoporosis and cardiovascular disease.^26,30,35 Research indicate that married women have a higher quality of life at menopause than single women and widows. Post-menopausal women with a higher quality of life are more likely to learn, do exercise and physical activity, and have healthy nutrition and behaviors.^25,43 Also, the increase in the age of the last pregnancy causes an increase in the age of menopause. Increasing the number of pregnancies and childbirth also raises the age of menopause, which may be due to increased estrogen and progesterone secretion due to increased uterine and ovarian activity and breastfeeding.^{29,30,44–46}

Conclusion

Regarding the broad impact of social determinants of health on menopause, the need for education and counseling for improving attitudes of women and their husbands toward menopause is felt. Besides, improving emotional and social support, planning for lifestyle enhancement, and improving socio-economic status is needed, which results in promoting women’s health during this period.