Measurement of Menopausal Symptoms using Greene Climacteric Scale in a Tertiary Care Centre in Uttarakhand, India

Abstract

Introduction: Menopause represents an important phase in a woman. Increase in life expectancy has resulted in prolongation of this phase. Aim: To identify the age of onset of natural menopause, associated symptoms of menopausal women attending the outpatient department of AIIMS Rishikesh, Uttarakhand, India. Materials and Methods: A hospital-based cross-sectional study was carried out in the Department of Obstetrics and Gynaecology of AIIMS Rishikesh, Uttarakhand, India. A total of 100 women having natural menopause over a period of five months were interviewed using Greene Climacteric Scale (GCS) questionnaire. The analysis was based on GCS and its various sub scores. Data analysis was carried out by SPSS version 17.0. Chi-square test, unpaired t-test, Pearson coefficient of correlation were used for statistical analysis. A p≤0.05 was considered as significant association. Results: The mean age at menopause was 47.2±4.62 years. Six percent of women had primary ovarian insufficiency. Urinary complaints (49 cases), backaches and lower abdominal pain (31 cases), hot flushes (24 cases), pruritus vulvae (15 cases) and musculoskeletal pain (15 cases) were most frequently self-reported menopausal symptoms in the present study. The most frequently reported symptoms as per GCS score were muscle and joint pain (87%), loss of libido (80%), insomnia (60%), hot flushes (54%) and feeling tired (30%). The mean number of symptoms reported by a single lady was 5.69±2.97 (ranged from 0-14). Regular physical activity or doing regular yoga was associated with lower total GCS score (9.50±6.1 vs. 11.18±5.6). Conclusion: Women in this region viewed menopause negatively. As observed in this study, symptoms were common and disturbing and hence cannot be ignored. Attempt should be made to treat menopausal symptoms starting from lifestyle management perspective in the form of yoga/exercise/calcium supplementation. © 2018, Journal of Clinical and Diagnostic Research. All rights reserved.

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Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): QC04-QC07
44
DOI: 10.7860/JCDR/2018/36441.12199
Original Article
Obstetrics and Gynaecology
Section
Measurement of Menopausal Symptoms
using Greene Climacteric Scale in a Tertiary
Care Centre in Uttarakhand, India
INTRODUCTION
Menopause represents the end of fertility in a woman’s life. It is,
in fact, a normal physiological state however, the transition to
menopause can significantly change the health and wellbeing of a
woman. Menopausal symptoms are mostly well tolerated but can
be really disturbing to some, thereby compromising their day to day
life.
With increase in life expectancy, a woman spends nearly 1/3rd of
her life in this phase [1]. The age at natural menopause worldwide
is 45-55 years [2]. In Asia as a whole, the proportion of the elderly
is expected to increase from 10.5 22.4% during 2012-2050. While
India is not expected to report more than 19% elderly by 2050, the
absolute numbers will be very large and a large proportion of this
will be formed by elderly females [3].
Literature search has shown that at least 60% of ladies suffer from
mild symptoms, 20% from severe symptoms and the rest 20% are
asymptomatic [4]. In Indian scenario, women usually seek advice
only when the symptoms are severe. At times, even if the symptoms
are bothering, they are unable to reach healthcare facilities owing
to a combination of socio-cultural, transportation difficulties and
economic instability; all these results in, under reporting of data.
Moreover, there is lack of awareness about menopause and its
effects among Indian women. Studies relating to perception of
menopause and its symptoms are less, especially in this region.
This study was planned to identify the age of onset of natural
menopause, associated symptoms and other health problems
of menopausal women attending the outpatient department of
AIIMS Rishikesh. The analysis was based on GCS and its various
subscores. This scale provides a brief measure of menopausal
symptoms. The GCS distinguishes 21 different symptoms clustered
into four subclasses-11 psychological symptoms (subdivided into
six anxiety and five depression symptoms), seven somatic/physical
symptoms, two vasomotor symptoms and one sexual symptom.
Each symptom ranges from 0 (not at all) to 3 (extremely) [5].
MATERIALS AND METHODS
This was a hospital-based, cross-sectional study. All women
presenting with menopausal symptoms in gynaecology outpatient
department were enrolled in the study, over a period of five months
from January 2015 to May 2015. Women with unnatural menopause
such as those having surgical menopause or radiotherapy induced
were excluded from this study. The study was approved by
Institutional Ethical Committee. A total of 117 women fulfilled the
inclusion criteria and were interviewed. Seventeen were rejected
during data analysis owing to incomplete completion of forms. Data
of 100 women was analysed. Women were interviewed using the
21 points GCS Questionnaire, after taking informed consent from
each participant.
Data regarding the demographic profile such as age, educational
status, parity, marital status, dietary patterns, smoking and alcohol
addictions, healthy lifestyle followers such as those doing regular
exercise/yoga and taking calcium supplementation were collected
RAJLAXMI MUNDHRA1, NIHARIKA DHIMAN2, JAYA CHATURVEDI3, SANDIPAN CHOWDHURI4
Keywords: Postmenopausal women, Psychological symptoms, Somatic symptoms, Urogenital symptoms
ABSTRACT
Introduction: Menopause represents an important phase in a
woman. Increase in life expectancy has resulted in prolongation
of this phase.
Aim: To identify the age of onset of natural menopause, associated
symptoms of menopausal women attending the outpatient
department of AIIMS Rishikesh, Uttarakhand, India.
Materials and Methods: A hospital-based cross-sectional study
was carried out in the Department of Obstetrics and Gynaecology
of AIIMS Rishikesh, Uttarakhand, India. A total of 100 women
having natural menopause over a period of five months were
interviewed using Greene Climacteric Scale (GCS) questionnaire.
The analysis was based on GCS and its various sub scores. Data
analysis was carried out by SPSS version 17.0. Chi-square test,
unpaired t-test, Pearson coefficient of correlation were used
for statistical analysis. A p≤0.05 was considered as significant
association.
Results: The mean age at menopause was 47.2±4.62 years.
Six percent of women had primary ovarian insufficiency. Urinary
complaints (49 cases), backaches and lower abdominal pain
(31 cases), hot flushes (24 cases), pruritus vulvae (15 cases)
and musculoskeletal pain (15 cases) were most frequently self-
reported menopausal symptoms in the present study. The most
frequently reported symptoms as per GCS score were muscle and
joint pain (87%), loss of libido (80%), insomnia (60%), hot flushes
(54%) and feeling tired (30%). The mean number of symptoms
reported by a single lady was 5.69±2.97 (ranged from 0-14).
Regular physical activity or doing regular yoga was associated
with lower total GCS score (9.50±6.1 vs. 11.18±5.6).
Conclusion: Women in this region viewed menopause
negatively. As observed in this study, symptoms were common
and disturbing and hence cannot be ignored. Attempt should
be made to treat menopausal symptoms starting from lifestyle
management perspective in the form of yoga/exercise/calcium
supplementation.

www.jcdr.net Rajlaxmi Mundhra et al., Profile of Menopausal Women in Women Visiting Outpatient Department of a Tertiary Centre in Uttarakhand
Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): QC04-QC07 55
of women had primary ovarian insufficiency. The present study
showed that in 23% women, symptoms started within two years
of menopause whereas 55% developed symptoms after five years
of menopause. Symptoms appearing after five years of menopause
were mostly musculoskeletal pain, which were probably attributed
to ageing. Sixty two percent of the women felt that menopause was
harmful whereas 38% believed that it was not harmful. Out of all
the study subjects, only 14% were aware of screening methods for
genital malignancy (they knew about PAP smear) and importance of
breast self examination. However there was a significant difference/
lag in awareness and practice as none of the women underwent
PAP screening or mammography [Table/Fig-2].
from each patient. Calcium supplementation as 500 mg oral tablets
was recorded. Duration of intake whether infrequently or as daily
once or twice dosing was recorded. Exercise in the form of brisk
walking for thirty minutes at least three times a week was accepted.
Women in this region practice yoga and simple breathing exercises
daily at least for 10-15 minutes in morning and this was also included.
Data regarding self reported menopausal symptoms and associated
comorbid conditions (diabetes, hypertension, thyroid diseases,
osteoarthritis, rheumatoid arthritis) were also noted. All patients had
routine height, weight and blood pressure measurements.
STATISTICAL ANALYSIS
Data analysis was carried out by SPSS version 17.0. Unpaired
t-test was used for statistical analysis. A p≤0.05 was considered as
significant association.
RESULTS
Demographic Profile of Study Population
The study population comprised of 100 women with natural
menopause. The mean age group of the study population was
56.33 years (range: 34-90 years). Dietary patterns revealed that
64% of the women were vegetarians. About 8% of the women were
addicted to bidi smoking (2-3 bidis/day) and 3% were alcoholics.
Only 20% were known to take calcium supplementation (13 cases
were taking it regularly since two years in twice daily oral dosing and
the rest seven women were taking it infrequently) and were engaged
in regular exercises (yoga/morning walk) [Table/Fig-1].
The mean age at menopause was 47.2±4.62 years. Six percent
Demographic Profile of Menopausal Women
Characteristics Frequency (%)
Age distribution
≤40 years 2
41-45 years 8
46-50 years 22
51-60 years 43
61-70 years 18
71-90 years 7
Mean age group (years) 56.33
Marital status
Married 83
Unmarried 0
Divorced 2
Widow 15
Educational status
Illiterate 60
Class 1-5 8
Class 6-10 15
Class 11-12 6
Graduate 8
Postgraduate 3
Occupation
Employed 13
Housewife 87
Dietary habits
Vegetarian 64
Non vegetarian 36
Smoking
Yes 8
No 92
Alcoholism
Yes 3
No 97
Calcium supplementation
Yes 20
No 80
Exercise
Yes 20
No 80
Parity
Nulliparous 6
Primiparous 9
Para 2-4 57
>4 28
[Table/Fig-1]: Demographic profile of menopausal women.
Age at menopause in years Frequency
<40 6
40-45 27
46-50 45
51-55 19
>=56 3
Mean age of menopause 47.2±4.62 years
Duration of development of symptoms
<24 months of menopause 23
2-5 years 22
5-10 years 20
>10 years 35
Awareness about menopause
Yes 92
No 8
Is menopause harmful
Yes 62
No 38
Awareness about PAP smear
Yes 14
No 86
[Table/Fig-2]: Age of menopause.
Urinary complaints (49%), backaches and lower abdominal pain
(31%), hot flushes (24%), pruritus vulvae (15%) and musculoskeletal
pain (21%) were most frequently self-reported menopausal
symptoms in the present study [Table/Fig-3].
The most frequently reported symptoms as per GCS score were
muscle and joint pain (87%), loss of libido (80%), insomnia (60%),
hot flushes (54%) and feeling tired (30%). The mean number
of symptoms reported by a single lady was 5.69±2.97 (ranged

Rajlaxmi Mundhra et al., Profile of Menopausal Women in Women Visiting Outpatient Department of a Tertiary Centre in Uttarakhand www.jcdr.net
Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): QC04-QC07
66
from 0-14). As seen in [Table/Fig-4], the mean total GCS score
was 10.9±5.75 (ranged from 0-27). The mean psychological sub
score was 4.26±3.89 (range 0-15), mean somatic sub score was
3.51±2.27 (range 0-10), mean vasomotor sub score was 1.27±1.42
(range 0-4) and mean sexual sub score was 1.88±1.16 (Range 0-3)
[Table/Fig-4].
from industrialised nations ranges from 50 to 52 years with onset
of perimenopause at 47.5 years [9-13]. Diversity in attainment of
menopause could be attributed to regional variation with association
of various genetic, lifestyle changes, environmental, cultural and
nutritional variation. In the present study, approximately 6% of
women attained menopause prior to 40 years as compared to 1.6%
in the study done by Singh A and Pradhan SK [14].
Mean age at menopause in smokers in present study was
45.87±5.98 years as compared to 47.34±4.55 years in non
smokers. Earlier studies have proved that women who smoke
stop menstruating one to two years earlier than comparable
nonsmokers [11,15] attributed to oocyte depletion.
This study showed that majority (62%) of the women believed
menopause to be harmful unlike Mahajan N et al., wherein 56%
women said that they were not affected by menopause [8]. Though
menopause is a reality, the perception varies among women. In the
Eastern societies, it is seen as a natural process and women hold a
positive attitude towards it [16,17].
An 86% of the studied sample was unaware of PAP smear, probably
attributed to lower educational status.
In present study, the type of symptoms noted were mainly muscle
and joint pain (87%), loss of libido (80%), insomnia (60%), hot
flushes (54%) and feeling tired (30%) were the most frequently
reported symptom unlike fatigue (62%), hot flashes (56%), cold
sweats (52%), and backaches (51%) in the study done by Mahajan
N et al., [8].
In the present study, 87% had muscle and joint pain whereas the
prevalence was only 59% in study done by Singh A et al., [14].
In a study by Haimov-Kochman R et al., in women aged 45-
55 years, the mean total GCS score was 19.4±11.8 (range
0-63), mean somatic subscore was 5.3±4.5 (range 0-23), mean
psychological sub score was 9.5±6.4 (range 0-28), mean sexual
subscore was 2.2±1.8 (range 0-3), mean vasomotor sub score
was 2.2±2 (0-6) [18]. Whereas in present study the mean GCS
score and mean sub score in all the clusters was lower. This
could probably be attributed to environmental and non sedentary
lifestyle of the study sample. Women in our sample were mostly
from hilly areas, but this needs further evaluation by a large scale
study to establish the possible relationship.
This study revealed that certain demographic and lifestyle parameters
affect menopausal symptoms. The present study mostly comprised
of lower socio-economic and illiterate females. Parity more than
four and doing yoga/regular exercise was significantly correlated
with less severe menopausal symptoms. A significant difference
was noted in terms of lower depression score in exercise and yoga
group (0.9±1.48 vs. 1.81±2.13, p=0.032). Regular physical activity
was associated with lower total GCS score and lower psychological
subscore in the study by Haimov-Kochman R et al., [18]. This effect
may be indirect as physical exercises increases physical self worth
and positive attitude, thus decreasing the bother from climacteric
symptoms. Haimov-Kochman R et al., also showed that high order
maternity was significantly associated lower psychologically sub
score whereas in present study parity >4 had significantly lower
vasomotor scores (0.64±1.026) as compared to those with parity
2-4 (1.5±1.5, p=0.047).
Sierra B et al., reported that age, higher parity and lower educational
level were associated to higher scorings for total and different cluster
of GCS [19]. Age, marital status, smoking educational status and
occupational status were not associated with lower total GCS score
in present study.
LIMITATION
A causal relationship could not be established because of its cross-
sectional design. Moreover, the change in the individual climacteric
score over the time could not be assessed. Strengths of this study
Self reported symptoms Frequency
Urinary problems 49
Lower abdominal pain, backache 31
Hot flushes 24
Uterovaginal prolapse 15
Vaginal dryness and pruritus vulvae 21
Muscle and Joint pain 21
Gastrointestinal problems 22
Postmenopausal bleeding 12
[Table/Fig-3]: Self-reported symptoms.
Score Minimum Maximum Mean Std. Deviation
Total score 0 27 10.90 5.752
Total symptoms 0 14 5.69 2.974
Anxiety score 0 12 2.61 2.643
Depression score 0 9 1.64 2.038
Somatic score 0 10 3.51 2.272
Vasomotor score 0 6 1.27 1.420
Sexual score 0 3 1.88 1.166
[Table/Fig-4]: Mean GCS score and sub score.
Regular physical activity or doing regular yoga was associated with
lower total GCS score (9.50±6.1 vs. 11.18±5.6), though the difference
was not statistically significant, although a significant difference was
noted in terms of lower depression score in exercise and yoga group
(0.9±1.48 vs. 1.81±2.13, p=0.032). Age, marital status, smoking
educational status and occupational status were not associated
with lower total GCS score. The study subjects with parity>4 had
significantly lower vasomotor scores (0.64±1.026) as compared to
those with parity 2-4 (1.5±1.5, p=0.047) [Table/Fig-5,6].
Score Exercise N Mean Std.
Deviation
Std. Error
Mean
Total score
yoga/exercise yes 20 9.50 6.160 1.377
yoga/exercise no 80 11.18 5.629 0.633
Depression score
yoga/exercise yes 20 0.90 1.483 0.332
yoga/exercise no 80 1.81 2.131 0.240
[Table/Fig-5]: Exercise and depression score.
Score N Mean Std. Deviation Std. Error
Vasomotor score
parity 0 6 1.17 1.329 0.543
parity 1 9 1.78 1.302 0.434
parity 2-4 57 1.51 1.537 0.204
parity >4 28 0.64 1.026 0.194
Total 100 1.27 1.420 0.142
[Table/Fig-6]: Parity and vasomotor score.
In terms of associated comorbid conditions, hypertension was
noted in 23% cases, diabetes in 9%, osteoarthritis knee in 6% and
thyroid diseases in 4%.
DISCUSSION
Mean age at menopause in the present study was 47.2±4.62 years,
similar to Bairy L et al., (48.70 years) [6]. However, it is higher in
comparison to the mean age at menopause as reported by Singh A
and Arora AK (44 years) and Mahajan N et al., (44.54 years) (Indian
studies) [7,8]. The median age at menopause among women

www.jcdr.net Rajlaxmi Mundhra et al., Profile of Menopausal Women in Women Visiting Outpatient Department of a Tertiary Centre in Uttarakhand
Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): QC04-QC07 77
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India.
2. Assistant Professor, Department of Obstetrics and Gynaecology, MAMC, Delhi, India.
3. Professor and Head, Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India.
4. Ex Senior Resident, Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Rajlaxmi Mundhra,
Assistant Professor, Department of Obstetrics and Gynaecology, AIIMS, Rishikesh-249203, Uttarakhand, India.
E-mail: rmundhra54@yahoo.com
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Mar 15, 2018
Date of Peer Review: May 04, 2018
Date of Acceptance: Jul 30, 2018
Date of Publishing: Nov 01, 2018
include-the study sample, though small represents the population
seeking medical consultation during menopause. It was one of a
few studies on menopause in this region. This study also noted self-
reported menopausal symptoms and then GCS was filled, thereby
avoiding recall bias.
CONCLUSION
The mean age at menopause was 47.2±4.62 years and 6%
women had primary ovarian insufficiency. Yoga/regular exercise
was significantly correlated with less severe menopausal
symptoms Muscle and joint pain (87%), loss of libido (80%),
insomnia (60%), hot flushes (54%) and feeling tired (30%) were the
most frequently reported symptoms. Women in this region viewed
menopause negatively. In order to tide over the menopausal
period, efforts should be made by the health care provider to
increase awareness about menopausal symptoms. Attempt
should be made to treat menopausal symptoms starting from
lifestyle management perspective in the form of yoga/exercise/
calcium supplementation. More studies with large sample size
needs to be done in this correlation.
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