Prevalence of somatic and urogenital symptoms as well as psychological health in women aged 45 to 55 attending primary health care: a cross-sectional study

Symptoms such as malaise, attention deficit, irritability, physical and psychological fatigue are more common today in all age groups, particularly in women. Poor mental health has now become the most common cause of sick leave with the greatest increase for women “in the prime of life” [17, 18]. It is apparent that women suffer long term sickness and ill health more than men [19, 20]. Hence, women in the age group 45–55 years are a very important target group for primary health care (PHC).

PHC is the basis of health care delivery in Sweden and is responsible for the basic needs of the population for healthcare, care of major public health diseases and primary prevention. It has the responsibility for the individual’s overall conditions and needs [21].

The district nurse (DN), also commonly labelled Advanced Practice Nurse (APN) in Primary Health Care with a multidisciplinary PHC background, together with midwifes plays an important and autonomous role in the Swedish PHC system [22]. In Swedish PHC, DN and midwives meet women aged 45–55 years with concerns about their bodily changes and psychological symptoms [23]. Many of these issues involve the normal changes of this phase of life, but cause much concern and increased perception of illness for some women [24]. Prevention based on a holistic approach leads to better care for women with these symptoms [25, 26].

Increased knowledge can improve existing primary care routines for these women. Despite a few studies [8, 27] there is still a lack of knowledge of the prevalence of somatic, psychological and urogenital symptoms as measured by the Menopause Rating Scale (MRS) and the Montgomery-Asberg Depression Rating Scale (MADRS) in PHC. The aim of this study was to estimate the prevalence of these symptoms in women attending PHC and evaluate factors associated with more severe symptoms.

For evaluation of the prevalence and severity of symptoms possibly related to the menopaue, as developed by Heinemann and validated in Sweden, was used [28, 29]. The Menopause Rating Scale (MRS) was developed in the early 1990s to measure severity of symptoms and their impact on quality of life on aging women. MRS is validated and was initially published in German. The first translation was from German to English followed by translation to Swedish. The MRS scale is used worldwide and translated into several languages [29]. The MRS is a self-administrated questionnaire consisting of eleven items, divided into three subscales reflecting; somatic symptoms - hot flushes, coronary discomfort, sleeping problems and muscle and joint problems; psychological symptoms - depressive mood, irritability, anxiety and physical and mental exhaustion; and urogenital symptoms - sexual problems, bladder problems and vaginal dryness. Each item ranged from 0 (not present) to 4 (1 = mild; 2 = moderate; 3 = severe; 4 = very severe). The MRS total score is the sum of the scores obtained for each subscale. Values equal or above 9 (somatic), 7 (psychological), 4 (urogenital), and 17 (total) were used to define severe menopausal symptoms [28].

The Montgomery–Åsberg Depression Rating Scale (MADRS) was 1979 by British and Swedish researchers to measure the severity of depressive episodes in patients with mood disorders [30, 31]. MADRS is validated and used worldwide The MADRS consists of nine questions, each scored from 0 to 6, where higher score indicates more severe symptoms. The nine questions in MADRS include the symptoms; 1) Apparent Sadness 2) Inner Tension 3) Reduced Sleep 4) Reduced Appetite 5) Concentration Difficulties 6) Lassitude 7) Inability to Feel 8) Pessimistic Thoughts and 9) Suicidal Thoughts. The total MADRS score was interpreted as follows; 0–6 no depression, 7–19 mild depression, 20–34 moderate depression, >34 severe depression [32].

The main strength of this study is the use of the validated self-reported questionnaire MRS and linking this to other symptoms in women attending PHC.

One weakness is that women were offered participation in a way that made it difficult to estimate the number of non-responders. Furthermore information about co-morbidities was not collected and cannot be adjusted for.

Our study indicated that age and some MRS related symptoms are related to menopause (Table 1). However, this relation is not seen in the multivariate analysis where menopause does not make it to the adjusted model (Table 4). However, this study was not designed to correlate symptoms to menopause but to correlate age, depression and miscellaneous factors to MRS related symptoms irrespective of menopause.

This study shows that psychological symptoms frequently reported were physical and mental exhaustion, decrease in concentration, inner tension and anxiety (Tables 2 and 3). Such symptoms may be related to mental stress or other problems around the women [34]. Stress related symptoms or crisis are not necessarily pathological but may imply an unhealthily prolonged psychological burden, reducing opportunities for recovery [34]. Mental illness has increased in the population and become a Swedish public health issue and seems to be more common among women than men [17, 35]. It is also the leading cause of long-term sick leave among women in Sweden [17]. It is shown that early prevention against mental illness and fatigue reduces future sick leave with significant financial gains for the women themselves, employers and the health care system [18, 35, 36]. Hence, it is important to focus on women’s mental health when they visit PHC.

Sleeping problems were the most prevalent reported symptom among women with moderately severe MRS related symptoms (Tables 2 and 3). Sleeping problems can increase the risk of developing mental illhealth and cardiovascular disease, highlighting the importance of sleep for a healthy life [12, 37]. Moreover, increased vulnerability and potentially greater psychological burdens at this age might also cause sleep problems [38]. Due to its high prevalence sleeping problems should be actively explored among women attending PHC for other menopausal symptoms.

Musculoskeletal pain is a disorder usually affecting middle aged women [8, 39] and this was also frequently reported in this study (Table 2). Muscle and joint pain is a common cause of sick leave and impaired self-rated health and sleep quality [17]. Furthermore, pain together with mental ill health are common reasons for long-term sick leave in Swedish women. Hence, musculoskeletal symptoms should be actively asked for in women attending PHC for other menopausal symptoms.

The incidence of cardiovascular disease (CVD) increases in the age 45–55 years [11, 12, 40]. In accordance with previous research almost half of the women in the present study had heart discomfort (Table 2) with awareness of heart beat, heart skipping, heart racing and tightness [11, 40]. Moreover, this risk may increase with mental illness and sleep problems [37, 38]. Thus, it is important to increase women’s awareness of any cardiovascular risk factors they may have [13, 41].

This study shows that a majority of women reported sexual problems such as reduced sexual desire, activity and satisfaction (Table 2) of moderate severity (Table 1). Moreover, about half of the women had bladder symptoms and vaginal dryness (Table 2) which is in line with previous studies [8]. A common cause is local oestrogen deficiency resulting in urinary incontinence, vaginal dryness, burning and pain during intercourse, itching and frequent urinary tract infections. All these symptoms may cause sexual problems and decreased sexual desire [42‐44]. Consequently, it is important to increase awareness about possible local estrogen deficiency and provide treatment if needed. Other possible causes for reduced sexual desire are miscellaneous changes in women’s daily lives and in relationships.

This study confirms previous findings of a high prevalence of mental illness and psychiatric symptoms during menopause [7, 17, 45, 46]. Furthermore, it seems that the prevalence of depression and menopausal symptoms increase with age (Table 4 and Fig. 1). This is a clinically relevant finding since a previous Swedish study showed that long-standing symptoms before a PHC consultation was associated with a prolonged recovery time, underlining the importance of early detection of these symptoms [23, 36, 47]. However, early detection of depression and mental ill health is difficult since one third of depressed women only mention somatic symptoms when visiting PHC [46].

The transition between 45 and 55 years of age is a natural change in a woman’s life and consequently seen as natural and positive by some, while others see it as unwanted. This period involves profound psychosocial changes such as children leaving home, care for aging parents, changes in marital relationships, and work-related illness [35, 47]. It is important to carefully evaluate symptoms of illness to sort out the true depression from other aspects of mental health illness and crisis reactions [17, 45‐47]. The latter can usually be prevented by having healthy social support [35].

A Swedish study revealed that girls in the transition phase (early puberty) should be informed early and before the first menstruation if they are to maintain their positive attitudes towards their body and menstruation [48]. It is possible that early information about health issues in the age group 45–55 is equally relevant for women before this time period occurs. Health education interventions for these women are likely to be beneficial for their knowledge and health [49, 50]. It should be explored in future studies if such preventative counseling of women attending PHC actually results in significantly reduced risk for future illness.