Prevalence and severity of menopause symptoms among perimenopausal and postmenopausal women aged 30-49 years in Gulele sub-city of Addis Ababa, Ethiopia

The World Health Organization (WHO) projects a rise in the proportion of adults over age 60 in sub-Saharan Africa from 46 million people in 2015 to 157 million by 2050 [1]. Similarly, sub-Saharan African women can expect an increased life expectancy at 76 years, on average. The prevalence of women experiencing menopause, commonly between the ages of 45 and 55, will also markedly increase. This population poses unique considerations given that sub-Saharan African women will spend a larger proportion of their lives in postmenopause. In Ethiopia alone, the 2007 National Census enumerated 9.7 million women aged 30 or older with 2.1 million in the menopausal age range of 45 to 55 years [2].

Menopause is a natural phenomenon signaling the reduction of ovarian function and onset of the last menstrual period and is generally diagnosed in retrospect since confirmation occurs only after a 12-month cessation of menstrual periods [3]. Perimenopause is defined as the transition prior to the last menstrual cycle, when a woman may experience variable or irregular menstrual cycles and hormonal fluctuations, and the 12 months after the final menstrual period. Premenopause is the stage after menarche but before entering menopausal stages with normal fertility function during this phase [4, 5]. Postmenopause is defined as the stage beginning 12 months after the last menstrual cycle [6].

As a woman enters perimenopause, her individual experiences may coincide with role changes and symptom experiences. Symptoms attributed to menopause vary between individuals and cultures, which has been attributed to general aging, menopausal fluctuations, or socially constructed phenomena [7]. The most commonly reported symptoms among women in high-income countries are vasomotor symptoms including hot flushes, vaginal dryness, insomnia, fatigue, and joint pain [8‐10]. Several studies conducted among Nigerian women reported menopausal symptoms of joint and bone pain, hot flush, insomnia, anxiety, urinary symptoms, fatigue, and dyspareunia [11‐13]. A study conducted among menopausal Ghanaian women reported tiredness, sleeplessness, palpitations, weight gain, hot flushes, and irritability as their common symptoms [14]. The majority of menopause research has been conducted primarily on Caucasian women from high-income countries, which may influence self-reported symptom in international studies. Inconsistent reports of hot flushes, sexual dysfunction, and depression were found across different ethnicities and countries [15]. The literature has been unclear about associations between menopausal experience with ethnicity, country of origin, or social construction. Furthermore, there is a paucity of research has been conducted on women living in low- and middle-income countries.

In Ethiopia, no known studies investigating the experience of perimenopause has been published. In the present study, we aim to add contextual knowledge to an urban Ethiopian population of women undergoing menopausal transition. We specifically explore prevalence and severity of symptoms among perimenopausal and postmenopausal women aged 30-49 in Gulele sub-city of Addis Ababa, Ethiopia. The restricted age range represents potential variation in entry into menopause, which mean age of menopause among urban Ethiopian women is limited. While the average age of menopause is 51 years globally, the average age varies across geographic regions and is unknown in Ethiopia. To the authors’ knowledge, this article will be the first publication in this sub-population and findings have implications to improve and expand upon menopausal health.

A total of 226 perimenopausal and postmenopausal women aged 30-49 years were included in the study. Among the sampled participants, the mean age was 38.9 years (SD ±5.4) for perimenopausal and 43.5 years (SD ±5.8) for postmenopausal women. Socio-demographic factors of participants included: 158 (69.9%) married, 79 (35.0%) completed secondary (high school) education, 94 (41.6%) full-time homemakers, 44 (19.5%) private sector employees, 40 (17.7%) civil servants, 161 (71.2%) Orthodox Christian, 41 (18.1%) Muslim, and 17 (7.5%) Protestant. Details of the background characteristics of study participants by menopause status are given in Table 1.

As the demographic shift within Ethiopia and the sub-Saharan African region moves towards an aging population and longer life expectancies, the importance of understanding health needs among older adults is relevant. While research on women in Ethiopia is being conducted, the focus has been on maternal and adolescent health but little attention has been paid to menopausal health. The Menopause Rating Scale is a globally recognized instrument measuring three symptomatic menopause categories with no existing publications gathering data on women from Addis Ababa, Ethiopia. In this study, we applied the first recorded use of the MRS in an urban Ethiopian population.

Women selected for participation in our study (n = 226) had a mean age of 40.4 years, were married, educated to secondary school level, identified with Amharan and Oromian ethnicities, and practiced Orthodox Christianity. The majority of women were aged 13 or older at menarche, which is consistent with the average age at menarche at 13.5 years among women in a review of 67 countries [26]. All participants included in this sub-analysis were in perimenopausal and postmenopausal stages with mean age at 38.9 and 43.5 years, respectively. Age at the last menstrual period for women in postmenopause was 42.6 years and the average age of duration of menopause (number of years since LMP) for postmenopausal women was 2.6 years. Since this study was the first to collect menopausal data in Addis Ababa, Ethiopia, the mean ages at menarche and menopause have yet to be reported nationwide to generalize ages to the larger population of Ethiopian women.

Ethiopian menopausal women experienced somatic symptoms (65.9%) most prevalently, followed by psychological (46.0%), and least prevalently, urogenital symptoms (30.5%). The five most commonly reported specific symptoms were: hot flushes (65.9%), difficulty falling asleep (50.0%), depressive moods (46.0%), irritability (45.1%) and anxiety (39.8%), which is consistent with literature in other diverse populations [13, 27, 28]. When assessing current menopausal status and symptoms, we found that postmenopausal women experienced higher proportions of nearly every type of menopausal symptoms while perimenopausal women reported lower frequency of symptoms. Among all participants, only 8.4% of women presented total MRS as severe. When considering the most commonly reported symptoms including hot flushes, sleep problems, depressive mood, irritability, anxiety for severity, most women reported their symptoms as mild.

Despite the growing population of aging women globally, few studies have been conducted on menopause in low- and middle-income countries. The sub-Saharan population found to have menopausal articles focused in Nigeria. Our research, similar the Nigerian studies, found high proportions of self-reported bone and joint pain, hot flushes, and physical and mental exhaustion [11‐13, 27]. Nigerian women tended to report symptoms as mild with only 8.6% of participants rating symptoms as severe, which is also consistent with our severe prevalence rate [13]. A recent Nigerian study found high prevalence of additional symptoms such as insomnia, headache, forgetfulness and palpitations [12]. However, different symptom types were reported in different proportions as compared to the Nigerian studies.

In this study, menopausal vasomotor symptoms, such as hot flushes and night sweats, were the most commonly reported symptoms. The potential to manage vasomotor symptoms using hormone therapy like low-dose oral estradiol or non-hormonal alternatives such as venlafaxine and paroxetine exists [29]. These treatments, in addition to greater awareness of menopausal symptoms and experiences, could form an open dialogue and approach to menopausal management in Addis Ababa.

Our current study has opportunities for expansion on more comprehensive background information, such as detailed medical history, family history, reproductive health experiences, and family member experiences. Additionally, anthropometric measures could be added such as height and weight to explore findings from three separate studies where researchers found that women with a higher body mass index reported more vasomotor symptoms [30‐32]. Other studies have evidenced high levels of physical activity with lower frequency of vasomotor symptoms [33]. Lifestyle factors like smoking and alcohol use have also been linked to hot flushes and earlier menopausal age [33‐35]. The onset of menopause and experience of symptoms are also influenced by reproductive factors such as women with low number of births no children, spent limited or no time breastfeeding, or had low usage of oral contraceptives reported an earlier onset of menopause [33]. Thus, we believe that future research potential on menopausal Ethiopian women could have far-reaching novel areas.

The current study has notable limitations. First, the study assessed only the prevalence and severity of menopause symptoms among women aged 30-49 years in the Gulele sub-city of Addis Ababa, Ethiopia. Our findings are not generalizable to the overall Ethiopian female population nor Addis Ababa. Second, the original study had an age restriction at 49 years to capture the perimenopausal stage but lacks samples of women further in postmenopause. Third, the study did not collect data on hormonal therapy use and/or other options for treatment of menopause symptoms. Finally, our study was a cross-sectional design, limiting ability to infer causality and confounding. Longitudinal studies addressing a larger population of Ethiopian women to assess menopause symptom experience and possible risk factors should be established. Given limitations in research infrastructure, our study conducted the most available research on this special population.

The prevalence and severity of menopause symptoms among perimenopausal and postmenopausal women aged 30-49 years residing in Gulele was assessed using the Menopause Rating Scale (MRS). The most commonly reported individual symptoms were: hot flushes, difficulty falling asleep, depressive moods, irritability and anxiety. The somatic, psychological, and urogenital subscale symptoms of menopause were higher among postmenopausal women compared to perimenopausal women. Women reported psychological menopause symptoms as the most severe experience.

Our initial results provide an opportunity for expansion into further studies to enumerate the true prevalence of menopause and menopausal symptoms in Ethiopia. The MRS instrument could be applied to different urban and rural populations. Future work should be conducted to better understand the unmet health needs of Ethiopian women entering or experiencing menopause.