Keywords
mind-body approach - Mindfulness meditation - menopausal symptoms - menopausal women
Introduction
The number of postmenopausal women has increased in the world because of the enhanced
lifestyle practices. With the aging of the worldwide population in the coming decades,
it is estimated that 1.2 billion women worldwide will be menopausal or postmenopausal
by the year 2030[1] and the common symptoms of menopause include vasomotor symptoms (hot flushes [HFs]
and/or night sweats), sleep disturbances, and vaginal dryness.[2] According to the Indian National Family Health Survey performed between 2005 and
2006, it was reported that nearly 18% of currently married women are in the age group
of 30 to 49 years and reached menopause.[3] The prevalence of vasomotor symptoms alone is estimated at approximately 40 to 50
million women in the United States.[4] As per the statistics of the United States in 2000, 27% of the population consisted
of women 45 years and older, whereas now it is estimated to be increased to 38%.[5] It is estimated that in the world wide nearly 85% of postmenopausal women have experienced
menopause-related symptoms in their lifetime[6] which makes them have impaired quality of life. In 2030, nearly half of females
will become postmenopausal and by 2060, the proportion of postmenopausal women will
be increased up to 59.8%.[7] It has been estimated that the average age for the onset of menopause among Indian
women is 47.5 years with an average life expectancy of 71 years.[8] Whereas, the median age at natural menopause among Caucasian women in Western society
is 50 years.[9]
Considering the limitation of hormone replacement therapy (HRT), the health professionals
are searching for different ways to manage menopause to minimize discomfort and inconvenience,
to improve the quality of life among peri and postmenopausal women.[10] The present study’s need is to explore new options for the management of menopausal
symptoms in the form of nonhormonal drug therapy and nonpharmacological measures.
The current recommendations are diet, regular exercise, change in lifestyle, yoga,
therapeutic massage, and other stress-reducing measures. Many treatments are available
to date for the management of menopause symptoms. Among all the available treatments,
dietary supplements, mind-body techniques, and yoga could play an effective role in
the management of menopausal symptoms due to less cost, time, and effort.[11] Moreover, these therapies have no side effects and from the literature, it is found
to be statistically significant. Hence, this study aimed to assess the effectiveness
of the mind-body approach to minimize menopausal symptoms among women.
Methods
Study Design and Participants
A quantitative research approach and quasi-experimental pretest–post-test design was
adopted to find the effect of mind-body approaches on menopausal symptoms among women
of Kotekar Primary Health Centre, Mangalore. A total of 20 samples between the ages
of 48 to 55 years with menopausal symptoms who fulfilled the inclusion criteria were
assigned into the study group. Exclusion criteria for study participants were: participants
who were regularly practicing meditation and yoga, participants with surgical menopause,
receiving any kind of HRT or anticoagulant therapy, participants with anxiety or mood
disorders, depression, schizophrenia, diabetes, hypertension, and cardiac diseases.
Data Collection Instruments
The data were collected using the socio-demographic proforma, self-reported menopausal
symptom checklist, and standardized menopausal rating scale (MRS). The sociographic
proforma consists of six items such as the age of the women, age at which menopause
is attained, educational status, nature of work of women, previous knowledge regarding
menopause, and any history of gastrointestinal disorders. The self-reported menopausal
checklist was used to allot the samples into the study group. The checklist consists
of 29 menopausal symptoms, which were classified and scored as mild, moderate, and
severe menopausal symptoms. Under the guidance of a gynecologist, it was finalized
that menopausal women with moderate and severe symptoms with an average of 6 and above
have been taken for the study. The level of menopausal symptoms was measured using
the standardized MRS. The domains included in the MRS scale were psychological scale,
Somato vegetative scale, and urogenital scale. The severity of menopausal symptoms
is categorized as follows: 0 to 14 (mild), 15 to 29 (moderate), and 30 to 44 (severe).
The standardized tools of the English version were translated to Kannada with the
help of language experts and retranslation was done to ensure language validity. The
internal consistency of the scales was calculated using the Karl Pearson correlation
coefficient and Cronbach’s α: MRS (r = 0.889).
Ethical Considerations
The Institutional Ethics Committee of Nitte Usha Institute of Nursing Sciences (Ref:
NUINS/CON/ NU/IEC/2016–17) and the Central Ethics Committee of Nitte University, Deralakatte
issued an ethical clearance certificate (Ref: NU/CEC/2018–2018/0143). The present
study fits into the principles defined in the Declaration of Helsinki[12] (World Medical Association, 2013). The study protocol was registered in CTRI and
the number is CTRI/2017/07/009071.
Data Collection Procedure
Before the data collection, an informed written consent and participant information
sheet was administered to the participants to assure confidentiality of data among
the participants, followed which, the participants’ menopausal symptoms were assessed
using a self-reported menopausal symptom checklist. Once the participants were allotted
to the study group their demographic proforma and preinterventional menopausal symptoms
were assessed on the first day of selection. The participants in the study group received
eight techniques of Mindfulness meditation (mind-body approach) i.e., counting 10
breaths and brief breathing meditation, Raisin meditation, Sitting meditation, Hatha
yoga, Body scan meditation, Loving-kindness meditation, Mindful walking meditation,
and Silent meditation. The mind-body approaches comprise an 8 weeks program which
includes 35 minutes of session per day with the help of audio clippings. The sessions
were led by the investigator. The investigator had training on Mindfulness meditation
and yoga. For Mindfulness meditation, the investigator had been to Behavioral Medicine
Unit, NIMHANS, Bangalore from August 01, 2019 to August 14, 2019, and for yoga at
Pranava yoga and Naturopathy center, Mangalore. After 8 weeks, the post-test was taken,
and the data analysis was done using SPSS 20.
Results
Baseline Information
The majority (80%) of the participants were in the age group of 51 to 53 years and
50% of the participants attained menopause between 49 and 50 years. Regarding education,
the majority of women had a high school education (60%). About the nature of the work
of women, all the menopausal women were semiskilled workers and their earnings are
up to Rs. 6,662/-. All the menopausal women were married, and the majority (80%) are
from a nuclear family. The majority (70%) of the menopausal women did not have previous
information regarding menopause and its management and among the women who received
the information are from family members (20%) and health professionals (10%) and none
of the participants were reported with any kind of gastrointestinal disorders among
the group ([Table 1]).
Table 1
Frequency (f) and percentage (%) distribution of demographic variables of participants
|
n = 20
|
|
Demographic variables
|
Frequency (f)
|
Percentage (%)
|
|
Age in years
|
|
|
|
48–50
|
2
|
10
|
|
51–53
|
16
|
80
|
|
54–55
|
2
|
10
|
|
Age at menopause (years)
|
|
|
|
45–46
|
4
|
20
|
|
47–48
|
6
|
30
|
|
49–50
|
10
|
50
|
|
Educational status of woman
|
|
|
|
Primary education
|
1
|
5
|
|
High school education
|
15
|
75
|
|
Higher secondary education
|
4
|
20
|
|
Nature of work of women
|
|
|
|
Semi-skilled worker
|
20
|
100
|
|
Income status of women/month (in INR)
|
|
|
|
2,425–6,662
|
20
|
100
|
|
Type of family
|
|
|
|
Nuclear family
|
18
|
90
|
|
Joint family
|
2
|
10
|
|
Previous information
|
|
|
|
Yes
|
6
|
30
|
|
No
|
14
|
70
|
|
Source of information
|
|
|
|
Family members
|
4
|
20
|
|
Health professionals
|
2
|
10
|
|
History of gastrointestinal disorders
|
|
|
|
No
|
20
|
100
|
The data in the [Table 2] shows that, the majority (70%) of the participants in the study group had a moderate
level of menopausal symptoms and 30% of the participants had severe level of menopausal
symptoms with a mean of 28.2 ± 1.476. Whereas in the post-test, 80% of the participants
reported with a mild level of menopausal symptoms, and 20% of them had a moderate
level of menopausal symptoms. It is also noticed that, in the post-test the severity
of menopausal symptoms has come down with a mean of 15.6 ± 2.633.
Table 2
Classification of menopausal symptoms among participants (pre and post intervention)
|
Level of menopausal symptoms
n = 20
|
Category
|
Pretest
|
Post-test
|
|
Respondents
|
Respondents
|
|
Frequency
(f)
|
Percentage
(%)
|
Frequency
(f)
|
Percentage
(%)
|
|
Mild
|
0–14
|
–
|
–
|
16
|
80
|
|
Moderate
|
15–29
|
14
|
70
|
4
|
20
|
|
Severe
|
30–44
|
6
|
30
|
|
|
|
Total
|
|
20
|
100
|
20
|
100
|
[Table 3] shows the domain wise comparison of menopausal symptoms scores among women. It depicts
that in the pretest, the domain on the psychological scale of the participants were
with mean ± SD of 11.10 ± 0.738, wherein the post-test the participants were with
mean ± SD of 7.30 ± 2.293. During the pretest in Somato vegetative scale, the participants
were with mean of ± SD of 8.50 ± 1.581, whereas, in the post-test, with mean ± SD
of 6.40 ± 1.776). It shows that in pretest the domain on the urogenital scale, the
participants were with mean ± SD of 8.70 ± 0.823, whereas, in the post-test they were
with mean ± SD of 3.40 ± 0.699.
Table 3
Domain wise comparison of menopausal symptoms score among women (pre- and post-interventional)
|
Domains
n = 20
|
Pretest
|
Post-test
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Abbreviation: SD, standard deviation.
|
|
Psychological scale
|
11.10
|
0.738
|
7.30
|
2.293
|
|
Somato vegetative scale
|
8.50
|
1.581
|
6.40
|
1.776
|
|
Urogenital scale
|
8.70
|
0.823
|
3.40
|
0.699
|
Data in [Table 4] show that the mean post-test menopausal symptom score was 15.60 ± 2.633 which was
lower than the mean pretest score 28.420 ± 1.476 and the calculated t-value t = 10.157 is greater than the table value (p < 0.001) at 0.001 level of significance. Hence, it is evident that the practice of
mind-body approach was effective in reducing the intensity of menopausal symptoms
among women.
Table 4
Effectiveness of a mind-body approach on menopausal symptoms using a paired t-test
|
Menopausal symptoms
n = 20
|
Mean
|
SD
|
Mean difference
|
t-Value
|
p-Value
|
|
Abbreviation: SD, standard deviation.
|
|
Pretest
|
28.420
|
1.476
|
12.600
|
13.011
|
p < 0.001
|
|
Post-test
|
15.60
|
2.633
|
Discussion
Psychological and behavioral interventions as well as yogic measures play a major
role in reducing menopause-related symptoms. The present study shows the baseline
information that, the majority (80%) of the participants were in the age group of
51 to 53 years and had high school education (60%). Similar findings were shown in
a research study conducted by Enjezab et al in Iran who reported that the mean age
of the women was 50.89 ± 2.527 years in the intervention group and 49.67 ± 2.733 years
in the control group and majority of them had primary education level.[13] Wong et al in China shows that the average age was 52.0 ± 3.09 years and 60.9% (n = 120) participants were in the perimenopausal stage during the intervention and
the present study shows that 50% of the participants attained menopause between 49
and 50 years.[14] The present study reported a reduction of total MRS scores mainly on the psychological
and Somato vegetative domains after the introduction of the mind-body approach. On
a psychological scale, the participants had the maximum score of 10 with mean 11.10
± 0.738, whereas, in the post-test, the score was 4 with a mean of 7.30 ± 2.293. In
Somato vegetative scale, the maximum score among women was 7 with a mean of 8.50 ±
1.581 whereas, in the post-test, the score was 4 with a mean of 6.40 ± 1.776. These
findings are in far from the study findings by Wong et al in China which demonstrated
that the effect of mindfulness-based stress reduction on the subscales of Greene Climacteric
Scale revealed a significant reduction of anxiety (F[1,35] = 7.53, p = 0.007) and depression (F[1,21] = 4.78, p = 0.031) but not on vasomotor, sexual, and urogenital subscales of menopausal symptoms.[14]
The study findings revealed that prior to intervention most of the subjects reported
having moderate menopausal symptoms with 30% having severe menopausal symptoms. The
intervention of the mind-body approach resulted in the mean post-test menopausal symptom
score i.e., 15.60, which was lower than the mean pretest scores, 28.420. The calculated
t-value (t = 13.011) is greater than the table value (t tab = 1.83, p < 0.001) at 0.001 level of significance and it revealed that the mind-body approach
significantly helps the menopausal women in reducing the severity of menopausal symptoms.
Similar findings reported in a study conducted by Joshi et al in Nagpur reported that
the total MRS scores in both the study group and control group were high on day 1;
mean total score of 9.37 + 7.28 in the study group and 9 + 6.76 in the control group,
but on day 90 the mean score was significantly less (P, 0.001) in the study group (4.36 + 4.8) compared with the control group (9.2 + 6.72).[15] The study findings consistent with another study conducted by Carmody reveals that
participants daily HF severity score, decreased to 40% over 11 weeks of the assessment
period.[16]
Implications of the Study
Studies to date suggest that mind-body therapies may hold promise for reducing vasomotor
and other symptoms of menopausal women. Empirical evidence gives a strong foundation
to implement these practices as a routine in the care of menopausal women with various
symptoms of menopause and also for reducing longer-term health effects of adverse
metabolic and cardiovascular changes associated with menopause. This study has significantly
contributed to the findings that mind-body therapies with the yoga-based practice
were effective in minimizing the vasomotor symptoms, anxiety, and enhancing self-esteem
among menopausal women.
Conclusion
The study concludes that mind-body approaches such as Mindfulness meditation had helped
to reduce the frequency, severity, and bothersomeness of menopausal hot flashes. Besides,
Mindfulness meditation also lessens the study participant’s depressive symptoms, anxiety,
and improved their self-esteem. The pilot study was found to be cost-effective and
feasible to be made as a routine intervention for menopausal women to manage depressive
symptoms as well to go ahead with the main study for the investigator. It is feasible
to state that Mindfulness meditation may be applied as a complementary therapy toward
post-menopausal women treatment.
