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The climacteric in Bandung, West Java Province, Indonesia. A survey of 1025 women between 40–55 years of age
321
Maturrtas, 6 (1984) 327-333 Elsevier
MAT 00326
The climacteric in Bandung, West Java province, Indonesia. A survey of 1025 women between 40-55 years of age T.
Agoestina 1 and P.A. van Keep 2
Department of Obstetrics and Gynecology, ’Hasan Sadikin Hospital, Bandung, Indonesia; ’ International Menopause Society, Brussels, Belgium (Received (Key words:
Climacteric
8 June 1984; accepted
complaints,
after revision 8 October
Age at menopause,
Developing
1984)
countries)
Introduction Various large-scale studies have been done into the symptoms which accompany the climacteric [l-5], and into the age at which the menopause occurs. However, most of these studies were undertaken in developed countries. Studies in developing countries are rare. Moore [9] reported on an investigation in Zimbabwe, and Sharma [lo] reported on a study in the Indian context. A number of anthropological studies in different tribes and ethnic groups do not provide quantitative data [11,12]. The paucity of data on climacteric complaints in developing countries is easily explainable. The climacteric is not a life-threatening condition and is therefore not of prime interest to researchers in the field of reproductive medicine. Sampling and interviewing may be relatively more difficult in such countries and the women may be less inclined to agree to be interviewed or may insist on being interviewed by females only [lo]. Such studies are of interest, however, because comparison of their results with studies done in the West may allow for the testing of hypotheses concerning the influence of the social and cultural context on symptom formation at the climacteric or concerning the influence of ethnicity, climate and nutritional status on climacteric complaints and age at menopause.
Material and Method A self-administered support and assistance
questionnaire study was initiated in 1981. Through the of the wife of the Governor of West Java, Indonesia, many
Correspondence to: Dr. Pieter van Keep, International Menopause Foundation, 8 avenue Don Bosco, 1150 Brussels, Belgium.
0378-5122/84/$03.00
0 1984 Elsevier Science Publishers
B.V.
Society,
c/o
International
Health
328
women’s organizations and clubs in Bandung, West Java, consisting of wives of government officials, nurses, midwives, teachers, wives of military men, etc., were given instruction on aiding others in the completion of the questionnaires. In December 1981 and January 1982 meetings were held at which the forms were distributed and all attending women between the ages of 40 and 55 were asked to complete them. Group leaders then checked the returned questionnaires for completeness. The number of completed questionnaires amounted to 1025. Non-response was extremely low. However, due to the sampling methodology, this sample is not claimed to be representative of the country, region or city. It is only a sample of organized women in Bandung, a large city in West Java with 1,400,OOO inhabitants, 700 m above sea level with a moderate tropical climate.
Results A total Table I.
TABLE
of 1025 questionnaires
were received.
The age distribution
I
AGE DISTRIBUTION
OF THE SAMPLE
Age (yr)
Number
%
40 40-44 45-49 50-54 55-59 59
9 417 317 217 63 2
0.9 40.7 30.9 21.2 6.1 0.2
1025
100
TABLE
is given
II
NUMBER OF PREGNANCIES, STILL LIVING AT HOME
LIVE BIRTHS,
OFFSPRING
STILL
ALIVE,
AND
OFFSPRING
0
l-3
4-7
8-12
13+
(a) pregnancies (b) live births (c) offspring still
2.6 3.4
20.0 21.8
44.7 49.7
28.6 23.0
4.1 2.3
alive (d) offspring still living at home
4.1 8.9
24.5 38.0
52.9 46.2
18.0 6.9
0.5 0.0
Percentage of all respondents reporting the indicated of:
in
329
TABLE
III
AGE OF THE YOUNGEST
CHILD.
o-3 yr 4-10 yr 11-20 yr 21-30 yr 31 or older No answer
8 38 43 8 1 2
905 respondents were married; 882 of these were still living with their husbands. 120 were single, divorced or widowed. Data on the number of pregnancies, live births, offspring still living and offspring still living at home are given in Table II. The age of the youngest child is given in Table III. Of all respondents 38.7% had completed elementary school only, 22.3% had completed junior high school, 32% senior high school and 6.9% had college or university educations. Seventy percent of the group were unemployed, while 22.3% had full time jobs and 7.7% had part-time jobs. The cumulative percentage for age at menarche is shown in Fig. 1. The percentage of women in each age group with no menstrual periods in the preceding 12 mth is given in Fig. 2. From this figure it appears that the age at menopause in this sample is 48 yr. The sample has been broken down by ‘menstrual status’, as defined by Jaszmann [13]. Forty-three percent still menstruated regularly (or not more irregularly than before) and were therefore pre-menopausal. Eleven percent reported that their menstruations were progressively more irregular but that they had had at least one menstrual period in the last 12 mth. These were classified as perimenopausal. Forty-six percent had no menstrual periods in the last 12 mth and were classified as postmenopausal.
Fig. 1. Age at menarche. 14 yr.
The curve shows the cumulative
percentage.
This line crosses the 50% just before
Fig. 2. Age at menopause. The curve shows the cumulative percentage of women who did not have menses in the last 12 mth. The line crosses the 50% at 48 yr. To obtain this curve, and to diminish the influence of digit preference (see text) the curve has been ‘smoothed’.
Usage of contraception was also surveyed. Of the women living with their husbands and still having periods (regular or irregular), a total of 589 (19.9%) had been sterilized, 25% had an intrauterine device (IUD), 7.3% used oral contraception and 1.7% used contraceptive injections. This does not mean that the remainder did not use other forms of contraception. Nine extragenital climacteric complaints were included in the questionnaire, four of which were predominantly circulatory: hot flushes, perspiration, palpitations and vertigo. Five were predominantly psychic: nervousness, irritability, headaches, depressed feelings and insomnia. Respondents were asked whether they had suffered in the past month from each of these and if so, how often (Tables IV-VII). For the circulatory complaints, women were asked if they had such symptoms, how often these appeared each day; less than three times, 3-10 times or more than 10 times. TABLE
IV
PERCENTAGES CLIMACTERIC
OF WOMEN SYMPTOMS.
A Hot flushes Perspiration Palpitations Vertigo B Nervousness Irritability Headache Depression Insomnia Note:
the frequency
IN
EACH
MENSTRUAL
AGE
GROUP
WHO
REPORTED
Pre-menopausal
Peri-menopausal
Post-menopausal
@J)
(g)
6)
9 14 21 46
13 28 36 53
12 25 34 55
< 0.001 -=z0.05 < 0.05
23 29 52 18 26
41 34 59 30 36
23 26 59 26 37
< 0.05 NS NS NS < 0.05
of symptoms
cannot
be read from this table.
P
-c 0.01
331
TABLE
V
PERCENTAGES OF WOMEN REPORTING ING TO MENSTRUAL STATUS.
Never <3 times 4-10 per I day +10
TABLE
THE FREQUENCY
OF HOT FLUSHES,
Pre-menopausal
Peri-menopausal
Post-menopausal
(%)
(Xl
(%)
92
87
89
8 3 2
10 1
8
VI
THE PERCENTAGES TION, ACCORDING
OF WOMEN REPORTING THE FREQUENCY TO MENSTRUAL STATUS.
OF BOUTS
OF PERSPIRA-
Pre-menopausal
Peri-menopausal
Post-menopausal
@)
(W)
@1
Never
86
72
74
(3
12 1 1
22 3 3
22 3 1
times 4-10 per I day +10
TABLE
ACCORD-
VII
THE PERCENTAGES OF WOMEN REPORTING ACCORDING TO MENSTRUAL STATUS.
Never l-3 days/mth 4-10 days/mth 10 or more days/mth
THE
FREQUENCY
OF
NERVOUSNESS
Pre-menopausal
Per&menopausal
Post-menopausal
(%)
(%)
(%)
77 22 1 0
59 36 3 2
77 21 2 0
For the predominantly psychic complaints women were asked to indicate the number of days per month such complaints were present: 1-3 days per month, 4-10 days or 11 days or more. Forty-five percent of all respondents had consulted a doctor for climacteric complaints. In the pre-, peri- and post-menopausal groups the percentages were 48, 56 and 40 respectively.
Discussion Data collection in a developing country is not easy. The sample is certainly not representative for Indonesia or even for the city of Bandung. Although the level of education of the sample is high, there will be some bias caused by faulty memory. This will be evident for events that happened in the past but may also influence the
332
recollection of recent events. We were surprised to find that the answers to the simple question of present age showed a strong digit preference, whereby subjects tended to round off their ages to the nearest zero or five. The same happened with height where answers clustered around 1.45, 1.50 and 1.55 m, and weight at 45, 50 and 55 kg. In calculating the age at menopause the number of postmenopausal women at each age has been considered. To diminish the influence of digit preference, the number of postmenopausal women in the preceding and following age group has been included in the calculation. Number of respondents 47 48 49 Total
Number of postmenopausal respondents
49 42 44
14 25 28
135
67
The percentage of postmenopausal women at age 48 is calculated as [(67/135) X 1001 = 49.6%. Similarly for age 49 the numbers for ages 48 and 50 have been taken into account. By this ‘smoothing’ of the curve, a mean age at menopause between 48 and 49 has been calculated. The percentage of perimenopausal women in each age group is small, reaching its highest value in the group of 46 yr (22.3%). This may indicate that the peri-menopause is rather short for women in Bandung and that they pass relatively quickly from a regular menstrual pattern into post-menopausal amenorrhea. This finding is confirmed by clinical impression. The pattern of climacteric complaints and symptoms is in general not different from that found in other epidemiological studies in the West. It is striking, however, that the most typical complaint, the hot flush, has less prevalence than the next one, bouts of perspiration. It is tempting to blame the climatic conditions for this difference. All complaints, with the exception of ‘headache’ are reported more often in the perimenopausal group and slightly less in the postmenopausal group, with the exception of insomnia which increases with menstrual age. In many aspects our findings do not differ so much from what would be expected in a study in a similar age group in a developed country. This may be partly explained by the fact that the sample is taken from an urban population, which has a relatively high level of education and who may, to some extent, have been exposed to Western style living. Yet in Indonesia the menopause and the climacteric have never been or hardly ever have been the subject of lay press publicity and it is this publicity which is regarded by some as an important factor in symptom formation at the end of the fertile period.
333
Acknowledgement
The statistical analysis by Ph. Lehert (FUCAM, acknowledged.
Mons, Belgium) is gratefully
References 1 Jaszmann L, van Lith ND, Zaat JCA. The perimenopausal symptoms: the statistical analysis of a survey Part A and B. Med. Gynaecol Social 1969; 4: 268-277. 2 Prill HJ. Die Beziehung von Erkrankungen und sozialpsychologischen Fakten zum Klimakterium. Med Klin 1966; 61: 1325. 3 Thompson, B, Hart SA, Durno D. Menopausal age and symptomatology in a general practice. J Biosoc Sci 1973; 5: 71. 4 M&inlay SM. Jefferys M. The menopausal syndrome. Br J Prev Sot Med 1973; 28: 108. 5 Van Keep PA. The menopause, a study of attitudes of women in Belgium, France, Great Britain, Italy and West Germany. Brussels/Geneva: International Health Foundation, 1970. 6 Van Keep PA, Brand PC, Lehert P. Factors affecting the age at menopause. In: Parkes AS, Herbertson MA, Cole J, eds. Fertility in middle age. J Biosoc Sci 1979; suppl 6: 37-58. 7 Brand PC. Age at menopause. Thesis, Utrecht, The Netherlands. 8 Jaszmann L, Van Lith ND, Zaat JCA. The age at menopause in the Netherlands. Int J Fertil 1969; 14: 106-117. 9 Moore B. Climacteric symptoms in an African Community. Maturitas 1981; 3: 25-29. 10 Sharma VK, Saxena MSL. Climacteric symptoms, a study in the Indian context. Maturitas 1981; 3: 11-20. 11 Flint MP. The menopause: reward or punishment? Psychosomatics 1975; 16: 161-163. 12 Flint MP. Transcultural influences in peri-menopause. In: Haspels AA, Musaph H, eds. Psychosomatics in peri-menopause, 1979; 41-56. 13 Jaszmann L. Epidemiology of climacteric and post-climacteric complaints. In: Van Keep PA, Lauritzen C, eds. Ageing and estrogens. Front. Horm. Res. vol. 2. Basel: Karger, 1973; 22-34.
Maturrtas, 6 (1984) 327-333 Elsevier
MAT 00326
The climacteric in Bandung, West Java province, Indonesia. A survey of 1025 women between 40-55 years of age T.
Agoestina 1 and P.A. van Keep 2
Department of Obstetrics and Gynecology, ’Hasan Sadikin Hospital, Bandung, Indonesia; ’ International Menopause Society, Brussels, Belgium (Received (Key words:
Climacteric
8 June 1984; accepted
complaints,
after revision 8 October
Age at menopause,
Developing
1984)
countries)
Introduction Various large-scale studies have been done into the symptoms which accompany the climacteric [l-5], and into the age at which the menopause occurs. However, most of these studies were undertaken in developed countries. Studies in developing countries are rare. Moore [9] reported on an investigation in Zimbabwe, and Sharma [lo] reported on a study in the Indian context. A number of anthropological studies in different tribes and ethnic groups do not provide quantitative data [11,12]. The paucity of data on climacteric complaints in developing countries is easily explainable. The climacteric is not a life-threatening condition and is therefore not of prime interest to researchers in the field of reproductive medicine. Sampling and interviewing may be relatively more difficult in such countries and the women may be less inclined to agree to be interviewed or may insist on being interviewed by females only [lo]. Such studies are of interest, however, because comparison of their results with studies done in the West may allow for the testing of hypotheses concerning the influence of the social and cultural context on symptom formation at the climacteric or concerning the influence of ethnicity, climate and nutritional status on climacteric complaints and age at menopause.
Material and Method A self-administered support and assistance
questionnaire study was initiated in 1981. Through the of the wife of the Governor of West Java, Indonesia, many
Correspondence to: Dr. Pieter van Keep, International Menopause Foundation, 8 avenue Don Bosco, 1150 Brussels, Belgium.
0378-5122/84/$03.00
0 1984 Elsevier Science Publishers
B.V.
Society,
c/o
International
Health
328
women’s organizations and clubs in Bandung, West Java, consisting of wives of government officials, nurses, midwives, teachers, wives of military men, etc., were given instruction on aiding others in the completion of the questionnaires. In December 1981 and January 1982 meetings were held at which the forms were distributed and all attending women between the ages of 40 and 55 were asked to complete them. Group leaders then checked the returned questionnaires for completeness. The number of completed questionnaires amounted to 1025. Non-response was extremely low. However, due to the sampling methodology, this sample is not claimed to be representative of the country, region or city. It is only a sample of organized women in Bandung, a large city in West Java with 1,400,OOO inhabitants, 700 m above sea level with a moderate tropical climate.
Results A total Table I.
TABLE
of 1025 questionnaires
were received.
The age distribution
I
AGE DISTRIBUTION
OF THE SAMPLE
Age (yr)
Number
%
40 40-44 45-49 50-54 55-59 59
9 417 317 217 63 2
0.9 40.7 30.9 21.2 6.1 0.2
1025
100
TABLE
is given
II
NUMBER OF PREGNANCIES, STILL LIVING AT HOME
LIVE BIRTHS,
OFFSPRING
STILL
ALIVE,
AND
OFFSPRING
0
l-3
4-7
8-12
13+
(a) pregnancies (b) live births (c) offspring still
2.6 3.4
20.0 21.8
44.7 49.7
28.6 23.0
4.1 2.3
alive (d) offspring still living at home
4.1 8.9
24.5 38.0
52.9 46.2
18.0 6.9
0.5 0.0
Percentage of all respondents reporting the indicated of:
in
329
TABLE
III
AGE OF THE YOUNGEST
CHILD.
o-3 yr 4-10 yr 11-20 yr 21-30 yr 31 or older No answer
8 38 43 8 1 2
905 respondents were married; 882 of these were still living with their husbands. 120 were single, divorced or widowed. Data on the number of pregnancies, live births, offspring still living and offspring still living at home are given in Table II. The age of the youngest child is given in Table III. Of all respondents 38.7% had completed elementary school only, 22.3% had completed junior high school, 32% senior high school and 6.9% had college or university educations. Seventy percent of the group were unemployed, while 22.3% had full time jobs and 7.7% had part-time jobs. The cumulative percentage for age at menarche is shown in Fig. 1. The percentage of women in each age group with no menstrual periods in the preceding 12 mth is given in Fig. 2. From this figure it appears that the age at menopause in this sample is 48 yr. The sample has been broken down by ‘menstrual status’, as defined by Jaszmann [13]. Forty-three percent still menstruated regularly (or not more irregularly than before) and were therefore pre-menopausal. Eleven percent reported that their menstruations were progressively more irregular but that they had had at least one menstrual period in the last 12 mth. These were classified as perimenopausal. Forty-six percent had no menstrual periods in the last 12 mth and were classified as postmenopausal.
Fig. 1. Age at menarche. 14 yr.
The curve shows the cumulative
percentage.
This line crosses the 50% just before
Fig. 2. Age at menopause. The curve shows the cumulative percentage of women who did not have menses in the last 12 mth. The line crosses the 50% at 48 yr. To obtain this curve, and to diminish the influence of digit preference (see text) the curve has been ‘smoothed’.
Usage of contraception was also surveyed. Of the women living with their husbands and still having periods (regular or irregular), a total of 589 (19.9%) had been sterilized, 25% had an intrauterine device (IUD), 7.3% used oral contraception and 1.7% used contraceptive injections. This does not mean that the remainder did not use other forms of contraception. Nine extragenital climacteric complaints were included in the questionnaire, four of which were predominantly circulatory: hot flushes, perspiration, palpitations and vertigo. Five were predominantly psychic: nervousness, irritability, headaches, depressed feelings and insomnia. Respondents were asked whether they had suffered in the past month from each of these and if so, how often (Tables IV-VII). For the circulatory complaints, women were asked if they had such symptoms, how often these appeared each day; less than three times, 3-10 times or more than 10 times. TABLE
IV
PERCENTAGES CLIMACTERIC
OF WOMEN SYMPTOMS.
A Hot flushes Perspiration Palpitations Vertigo B Nervousness Irritability Headache Depression Insomnia Note:
the frequency
IN
EACH
MENSTRUAL
AGE
GROUP
WHO
REPORTED
Pre-menopausal
Peri-menopausal
Post-menopausal
@J)
(g)
6)
9 14 21 46
13 28 36 53
12 25 34 55
< 0.001 -=z0.05 < 0.05
23 29 52 18 26
41 34 59 30 36
23 26 59 26 37
< 0.05 NS NS NS < 0.05
of symptoms
cannot
be read from this table.
P
-c 0.01
331
TABLE
V
PERCENTAGES OF WOMEN REPORTING ING TO MENSTRUAL STATUS.
Never <3 times 4-10 per I day +10
TABLE
THE FREQUENCY
OF HOT FLUSHES,
Pre-menopausal
Peri-menopausal
Post-menopausal
(%)
(Xl
(%)
92
87
89
8 3 2
10 1
8
VI
THE PERCENTAGES TION, ACCORDING
OF WOMEN REPORTING THE FREQUENCY TO MENSTRUAL STATUS.
OF BOUTS
OF PERSPIRA-
Pre-menopausal
Peri-menopausal
Post-menopausal
@)
(W)
@1
Never
86
72
74
(3
12 1 1
22 3 3
22 3 1
times 4-10 per I day +10
TABLE
ACCORD-
VII
THE PERCENTAGES OF WOMEN REPORTING ACCORDING TO MENSTRUAL STATUS.
Never l-3 days/mth 4-10 days/mth 10 or more days/mth
THE
FREQUENCY
OF
NERVOUSNESS
Pre-menopausal
Per&menopausal
Post-menopausal
(%)
(%)
(%)
77 22 1 0
59 36 3 2
77 21 2 0
For the predominantly psychic complaints women were asked to indicate the number of days per month such complaints were present: 1-3 days per month, 4-10 days or 11 days or more. Forty-five percent of all respondents had consulted a doctor for climacteric complaints. In the pre-, peri- and post-menopausal groups the percentages were 48, 56 and 40 respectively.
Discussion Data collection in a developing country is not easy. The sample is certainly not representative for Indonesia or even for the city of Bandung. Although the level of education of the sample is high, there will be some bias caused by faulty memory. This will be evident for events that happened in the past but may also influence the
332
recollection of recent events. We were surprised to find that the answers to the simple question of present age showed a strong digit preference, whereby subjects tended to round off their ages to the nearest zero or five. The same happened with height where answers clustered around 1.45, 1.50 and 1.55 m, and weight at 45, 50 and 55 kg. In calculating the age at menopause the number of postmenopausal women at each age has been considered. To diminish the influence of digit preference, the number of postmenopausal women in the preceding and following age group has been included in the calculation. Number of respondents 47 48 49 Total
Number of postmenopausal respondents
49 42 44
14 25 28
135
67
The percentage of postmenopausal women at age 48 is calculated as [(67/135) X 1001 = 49.6%. Similarly for age 49 the numbers for ages 48 and 50 have been taken into account. By this ‘smoothing’ of the curve, a mean age at menopause between 48 and 49 has been calculated. The percentage of perimenopausal women in each age group is small, reaching its highest value in the group of 46 yr (22.3%). This may indicate that the peri-menopause is rather short for women in Bandung and that they pass relatively quickly from a regular menstrual pattern into post-menopausal amenorrhea. This finding is confirmed by clinical impression. The pattern of climacteric complaints and symptoms is in general not different from that found in other epidemiological studies in the West. It is striking, however, that the most typical complaint, the hot flush, has less prevalence than the next one, bouts of perspiration. It is tempting to blame the climatic conditions for this difference. All complaints, with the exception of ‘headache’ are reported more often in the perimenopausal group and slightly less in the postmenopausal group, with the exception of insomnia which increases with menstrual age. In many aspects our findings do not differ so much from what would be expected in a study in a similar age group in a developed country. This may be partly explained by the fact that the sample is taken from an urban population, which has a relatively high level of education and who may, to some extent, have been exposed to Western style living. Yet in Indonesia the menopause and the climacteric have never been or hardly ever have been the subject of lay press publicity and it is this publicity which is regarded by some as an important factor in symptom formation at the end of the fertile period.
333
Acknowledgement
The statistical analysis by Ph. Lehert (FUCAM, acknowledged.
Mons, Belgium) is gratefully
References 1 Jaszmann L, van Lith ND, Zaat JCA. The perimenopausal symptoms: the statistical analysis of a survey Part A and B. Med. Gynaecol Social 1969; 4: 268-277. 2 Prill HJ. Die Beziehung von Erkrankungen und sozialpsychologischen Fakten zum Klimakterium. Med Klin 1966; 61: 1325. 3 Thompson, B, Hart SA, Durno D. Menopausal age and symptomatology in a general practice. J Biosoc Sci 1973; 5: 71. 4 M&inlay SM. Jefferys M. The menopausal syndrome. Br J Prev Sot Med 1973; 28: 108. 5 Van Keep PA. The menopause, a study of attitudes of women in Belgium, France, Great Britain, Italy and West Germany. Brussels/Geneva: International Health Foundation, 1970. 6 Van Keep PA, Brand PC, Lehert P. Factors affecting the age at menopause. In: Parkes AS, Herbertson MA, Cole J, eds. Fertility in middle age. J Biosoc Sci 1979; suppl 6: 37-58. 7 Brand PC. Age at menopause. Thesis, Utrecht, The Netherlands. 8 Jaszmann L, Van Lith ND, Zaat JCA. The age at menopause in the Netherlands. Int J Fertil 1969; 14: 106-117. 9 Moore B. Climacteric symptoms in an African Community. Maturitas 1981; 3: 25-29. 10 Sharma VK, Saxena MSL. Climacteric symptoms, a study in the Indian context. Maturitas 1981; 3: 11-20. 11 Flint MP. The menopause: reward or punishment? Psychosomatics 1975; 16: 161-163. 12 Flint MP. Transcultural influences in peri-menopause. In: Haspels AA, Musaph H, eds. Psychosomatics in peri-menopause, 1979; 41-56. 13 Jaszmann L. Epidemiology of climacteric and post-climacteric complaints. In: Van Keep PA, Lauritzen C, eds. Ageing and estrogens. Front. Horm. Res. vol. 2. Basel: Karger, 1973; 22-34.