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A prospective study of the frequency of acute menopausal symptoms in Hong Kong Chinese women
Maturitas 18 (1994) 175-181
A prospective study of the frequency of acute menopausal symptoms in Hong Kong Chinese women C. J. Haines* a, T.K.H. Chug”,
D.H.Y. Leungb
‘Department of Obstetrics and Gynaecology. bCentre for Clinical Trials and Epidemiological Research, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
(Received 26 March 1993; revision received 26 May 1993; accepted 9 June 1993)
Abstract
A prospective study was conducted amongst Hong Kong Chinese women to determine the incidence of acute menopausal symptoms following surgical menopause. Cases where a laparotomy was performed for other indications were used as controls. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%), respectively, of those women having had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Whilst vasomotor symptoms were more frequent in those women who had undergone a surgical menopause than in the controls, women in this population were shown to suffer fewer symptoms than has been demonstrated in Caucasian women. Although this study does not help to explain why such differences exist, the relative absence of symptoms may contribute to the low demand for hormone replacement therapy in Hong Kong and other countries where climacteric symptoms are relatively infrequent. Key words: Menopause; Climacteric symptoms
1. Intraduction The development
of acute menopausal
symptoms
has been demonstrated
to be
more frequent and severe in those women having had a surgical rather than a spontaneous menopause [l]. The most common complaints are those of hot flushes and sweating and these have been reported to occur in 70% and 84%, respectively, of Corresponding author.
??
0378-5122/94/%07.00
0
1994 Elsevier Science Ireland
SSDI 0378-5122(93)00776-P
Ltd. All rights reserved.
176
C.J. Haines et al. /Maturitas 18 (1994)
175-181
Caucasian women following a surgical menopause and 60% and 74% after a spontaneous menopause [2]. Some cross-cultural differences in the reporting of menopausal symptoms have been demonstrated [3-51. Our experience in one of the few specialist hormone replacement clinics in Hong Kong suggested that postmenopausal women in this population experienced fewer symptoms than their Caucasian counterparts. Self-referral to these clinics was unusual, with the majority of patients presenting through internal referral after a surgical or premature menopause. The purpose of this study was to examine the frequency of acute menopausal symptoms to determine whether this was a factor which may have accounted for the relatively low demand for hormone replacement therapy (HRT) in this population. 2. Subjects and methods A prospective study was conducted amongst 79 women over 35 years of age who were to undergo laparotomy for any indication. Details of the study group are presented in Table 1. All women were surveyed preoperatively by a Cantonese (Chinese) speaking doctor regarding eight commonly reported acute menopausal symptoms (Table 2). Cantonese is the language spoken by the majority of the Chinese population living in Hong Kong and was the primary language of all subjects included in the study. The accepted translation for each menopausal symptom was read out identically at each of the three interviews. As an example, the Cantonese for hot flushes, loosely translates as ‘for no reason, face gets hot and red’. The duration and frequency of hot flushes were recorded, but the enquiry for the other symptoms was limited to their presence or absence. The subjects were divided into three groups, those having had total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) (Group I), those having total abdominal hysterectomy (TAH) alone (Group II) and the remainder with a laparotomy for other indications such as ovarian cystectomy and ectopic pregnancy (Group III). Those in Table 1 Characteristics of the three study groups Group I (TAHBSO) (n = 33) Age’(STD) Education (%) None Primary Secondary Tertiary Employed (%) Salary’*b (STD) Family incomea+b (STD)
46.0 (6.8) 6 (18.2) 18 (54.5) 9 (27.3) 0 17 (51.5) 4064.7 1 (2389.18) 8395.95 (4269.47)
“Presented as mean values. bPresented in Hong Kong dollars in parentheses.
Group II (TAH) (ii = 33) 39.9 (7.7) 4 (12.2) 17 (51.5) 11 (33.3) I (3.1) 15 (45.4) 3566.67 (1537.39) 8328.13 (4004.14)
Group 111 (Other) (n = 13) 36.1 (5.6) I (7.8) 6 (46.1) 6 (46.1) 0 7 (53.8) 4042.86 (1345.74) 8461.54 (1272.75)
7 I2 I8 I5
I4 8
Insomnia Headaches Memory disturbance Irritability
Anxiety Urinary tract disturbance
I 8
8 3 I I
2 6
5 7
II 3 9 7
8 6
Final
8 IO
6 9 6 II
2 3
Preop
II
3 4
9 I 1 2
3 9
Postop
symptoms
3 I
4 4 5 0
0 3
Final
the oophorectomized
who developed
(TAH) (n = 33)
Group
between
of patients
symptoms
Numbers in the Postop and Final columns represent the number the number of patients with symptoms preceding surgery.
2 4
Preop
(n = 33)
Postop
of acute menopausal
Group I (TAHBSO)
of the development
Hot flushes Sweating
Table 2 A comparison
following
surgery.
6 6
4 4 6 6
0 0
Preop
(n = 13)
Numbers
I 2
2 2 0 0
I 4
Postop
groups
Group III (Laparotomy)
and the two control
in the Preop column
2 2
2 2 2 3
2 0
Final
represent
178
C.J. Haines et al. /Maturitas I8 (1994)
175-181
Group II were examined separately as it has been suggested that a hysterectomy alone may still interfere with ovarian blood supply and therefore potentially result in symptoms which would not be present in those women having had a laparotomy for other indications [6]. The women were not told that this study was specifically related to the menopause, but rather that it was a survey to investigate any delayed effects of their operative treatment. The same questions were repeated postoperatively on the day of hospital discharge and again no sooner than their 6 week postoperative outpatient visit. At the final visit all subjects were invited to volunteer any additional symptoms which had developed following surgery. For the analysis of data involving observations on a continuous scale, I-tests were performed. For data involving counts, Chi-square or Fisher’s exact test was used. For data analysed with the Chi-square or Fisher’s exact test, some grouping of the data was necessary. For all tests, P < 0.05 was considered significant. 3. Results The survey group comprised 33 women in Group I, 33 in Group II and 13 in Group III. All women included in the study were interviewed on the preoperative day and again between days 3 and 17 postoperatively (mean 6.5 days). The final interview was conducted on or after the 6-week postoperative follow-up (mean 75.3 days, range 25-363). A summary of the responses is presented in Table 2. The mean age of the women in Group I was greater than that in either of the other two groups (P = 0.001). There was no difference in the level of education, employment, salary nor family income between the three groups. Pre-existent symptoms were present in all of the three groups. There was no difference in the frequency of vasomotor symptoms between the three groups at the preoperative survey, but those subjects in Groups I and II complained of memory disturbances more frequently than those in Group III (P = 0.004). In those with hot flushes, these were reported at a mean frequency of 1S/h and a duration of 1.3 min. Headaches, memory disturbances, irritability and anxiety were more commonly reported preoperatively in all groups than at the postoperative or final interview, but these differences were not significant. At the postoperative interview (conducted before hospital discharge), there were no differences in the development of vasomotor nor other symptoms between the three operative groups. Hot flushes and sweating appeared in 2/33 (6.1%) and 6/33 (18.2%), respectively, of those women in Group I, 3/33 (9.1%) and 9/33 (27.3%) in Group II and l/l3 (7.7%) and 4/13 (30.8%) of those in Group III. Hot flushes occurred with a mean frequency of 2.3/h and lasted 2.2 min. At the final interview, hot flushes and sweating had developed more frequently in Group I than in Group II (P = 0. 001, P = 0.023). Whilst sweating was more frequent amongst those in Group I compared with Group III subjects (P = 0.015), there was no difference in the reporting of other symptoms between these two groups. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%), respectively, in Group I, O/33 and 3/33 (9.1%) in Group II and in 2/13 (15.4%) and 0113 in Group III. There was a mean of 3.8 hot flushes per hour, lasting 1.4 min. Insomnia, memory disturbances, irritability and urinary disorders were also more
C.J. Haines et al. lh4aturitas 18 (1994)
175-181
179
common amongst women in Group I than those in Group II (P = 0.013, P = 0.003, P = 0.001, P = 0.024, respectively). There was no consistent pattern of response regarding the development of any other symptoms following surgery. When comparing the two control groups (Groups II and III), there was a greater incidence of hot flushes and irritability after 6 or more weeks in those subjects having had a laparotomy than in those with a TAH (P = 0.025, P = 0.001). This difference was not present at the immediate postoperative interview. 4. Discussion Previous surveys conducted amongst Caucasian women undergoing a spontaneous menopause have indicated that hot flushes and night sweats are associated with the onset of menopause and occur in the majority of women. In a study of 100 patients who had undergone a surgical menopause, 94 experienced vasomotor symptoms as the first climacteric symptom, with 50 developing this problem before hospital discharge and 84 within 6 weeks of operation [5]. In this study, apart from age, there was no difference in social characteristics between the three groups. The fact that women in Group I were older meant that TAHBSO was more likely to be performed than hysterectomy with conservation of the ovaries. There were no differences in the incidence of vasomotor symptoms between the groups at the preoperative interview. The fact that headaches, memory disturbances, irritability and anxiety were more frequent complaints preoperatively in all groups may have been a reflection of the level of anxiety which may have been expected of a patient on the day preceding a surgical procedure. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%) women, respectively, following a surgical menopause. (Hot flushes and sweating were already present in 2 and 4 women, respectively, before surgery.) Whilst these symptoms occurred in a significantly greater number of women in this group than amongst those who had undergone a laparotomy for other indications, the reporting of these symptoms occurred much less frequently than has been documented in Caucasian women. The division of the controls into two subgroups rather than one may have been unnecessary. There was a significantly greater incidence of vasomotor symptoms in the oophorectomized women compared with either of the control groups, suggesting that those women who had a hysterectomy alone did not suffer significant interference with ovarian blood supply. Whilst blood was taken in the majority of cases to confirm that those having had a TAHBSO had become menopausal, there were not enough cases in the control groups with complete blood results to allow a comparison of hormonal outcome between those patients having hysterectomy and those with a laparotomy for other indications. The fact that there was no difference in the onset of hot flushes between those having TAHBSO and the group having a laparotomy may be a reflection of the small numbers included in the latter group. The incidence of vasomotor symptoms reported at the interview before hospital discharge may have been an overestimate. The incidence of sweating was higher in all groups than that of hot flushes and may have been due to the presence of low grade fever which frequently accompanies major surgery. Hot flushes, however, were
180
C.J. Haines et al. /Maturitas 18 (1994)
175-181
not usually reported at the interview conducted before discharge, which was contrary to our experience with Caucasians and also to the reported experience of others [71. A number of factors may influence the frequency with which postmenopausal women use HRT. These include the attitude of the medical practitioner, the preference of the patient, the presence of any contraindications and the severity of symptoms. Various studies have reported on the effect of cultural factors on the frequency and severity of climacteric symptoms. Apart from the cessation of menses, relatively few symptoms were present amongst Rajput caste women in India [8] and there were similar findings in a study of Arabian women [9]. Of those populations which are in the same region as Hong Kong, Japanese women have very few symptoms [4], but 69% of Thai women in Bangkok reported hot flushes and other climacteric symptoms were also common [3]. In our own population, ongoing research suggests that whilst women in Hong Kong are familiar with the fact that menstruation ceases at around 50 years of age, there is very little knowledge about associated short- and long-term effects of the menopause and also almost no knowledge of available treatment. This prospective study was biased by the leading nature of the questioning for the presence of acute menopausal symptoms and also by the selection of a surgical rather than a naturally occurring menopause. Despite the introduction of this bias, the symptoms most commonly suffered by postmenopausal Caucasian women were reported much less frequently in this population. Some women reported severe vasomotor symptoms, but the numbers were very few. We remain uncertain why there was a low incidence of symptoms in this study group, or why cross-cultural differences exist. The study design would have been more likely to result in an overestimate of the occurrence of symptoms than an underestimate. Similarly, climatic conditions would have been unlikely to have affected the results as the study was conducted in summer, when sweating may have been more frequent. This relative absence of symptoms is of relevance to the provision of satisfactory health care to postmenopausal women in Hong Kong and in other countries where symptoms are infrequent. The combination of a low incidence of symptoms accompanied by little knowledge of the potentially serious long-term sequelae of oestrogen deficiency means that many women in these areas who could benefit from hormone replacement therapy will not receive treatment. 5. References I
2 3 4 5
McKinley SM, Jeffrys M. The menopausal syndrome. Br J Prev Sot Med 1974; 28: 108-l 15. Hagstad A, Janson PO. The epidemiology of climacteric symptoms. Acta Obstet Gynecol Stand Suppl 1986; 134: 59-65. Sukwatana P, Meekhangvan J, Tamrongterakul Y, Tanapat Y, Asavarait S, Boonjitrpimon P. Menopausal symptoms among Thai women in Bangkok. Maturitas 1991; 13: 217-228. Lock M. Ambiguities of aging: Japanese experience and perceptions of menopause. Cult Med Psychiatry 1986; 10; 23-46. Beyene Y. Cultural significance and physiological manifestations of menopause. A biocultural analysis. Cult Med Psychiatry 1986; IO: 47-71.
C.J. Haines et al. /Maturitas
6
I 8 9
18 (1994)
175-181
181
Whitehead M, Godfree V. Hormone Replacement Therapy - Your Questions Answered. First Edition. Edinburgh: Churchill Livingstone, 1992. Chakravarti S, Collins WP, Newton JR, Studd JWW. Endocrine changes and symptomatology after oophorectomy in premenopausal women. Br J Obstet Gynaecol 1977; 84: 769-775. Flint MP. Sociology and anthropology of the menopause. In: Van Keep PA, Serr DM, Greenblatt RB, eds. Female and male climacteric, Lancaster: MTP Press, 1979; l-8. Maoz B. The perception of the menopause in five ethnic groups in Israel (Thesis), Leiden, 1973.
A prospective study of the frequency of acute menopausal symptoms in Hong Kong Chinese women C. J. Haines* a, T.K.H. Chug”,
D.H.Y. Leungb
‘Department of Obstetrics and Gynaecology. bCentre for Clinical Trials and Epidemiological Research, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
(Received 26 March 1993; revision received 26 May 1993; accepted 9 June 1993)
Abstract
A prospective study was conducted amongst Hong Kong Chinese women to determine the incidence of acute menopausal symptoms following surgical menopause. Cases where a laparotomy was performed for other indications were used as controls. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%), respectively, of those women having had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Whilst vasomotor symptoms were more frequent in those women who had undergone a surgical menopause than in the controls, women in this population were shown to suffer fewer symptoms than has been demonstrated in Caucasian women. Although this study does not help to explain why such differences exist, the relative absence of symptoms may contribute to the low demand for hormone replacement therapy in Hong Kong and other countries where climacteric symptoms are relatively infrequent. Key words: Menopause; Climacteric symptoms
1. Intraduction The development
of acute menopausal
symptoms
has been demonstrated
to be
more frequent and severe in those women having had a surgical rather than a spontaneous menopause [l]. The most common complaints are those of hot flushes and sweating and these have been reported to occur in 70% and 84%, respectively, of Corresponding author.
??
0378-5122/94/%07.00
0
1994 Elsevier Science Ireland
SSDI 0378-5122(93)00776-P
Ltd. All rights reserved.
176
C.J. Haines et al. /Maturitas 18 (1994)
175-181
Caucasian women following a surgical menopause and 60% and 74% after a spontaneous menopause [2]. Some cross-cultural differences in the reporting of menopausal symptoms have been demonstrated [3-51. Our experience in one of the few specialist hormone replacement clinics in Hong Kong suggested that postmenopausal women in this population experienced fewer symptoms than their Caucasian counterparts. Self-referral to these clinics was unusual, with the majority of patients presenting through internal referral after a surgical or premature menopause. The purpose of this study was to examine the frequency of acute menopausal symptoms to determine whether this was a factor which may have accounted for the relatively low demand for hormone replacement therapy (HRT) in this population. 2. Subjects and methods A prospective study was conducted amongst 79 women over 35 years of age who were to undergo laparotomy for any indication. Details of the study group are presented in Table 1. All women were surveyed preoperatively by a Cantonese (Chinese) speaking doctor regarding eight commonly reported acute menopausal symptoms (Table 2). Cantonese is the language spoken by the majority of the Chinese population living in Hong Kong and was the primary language of all subjects included in the study. The accepted translation for each menopausal symptom was read out identically at each of the three interviews. As an example, the Cantonese for hot flushes, loosely translates as ‘for no reason, face gets hot and red’. The duration and frequency of hot flushes were recorded, but the enquiry for the other symptoms was limited to their presence or absence. The subjects were divided into three groups, those having had total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) (Group I), those having total abdominal hysterectomy (TAH) alone (Group II) and the remainder with a laparotomy for other indications such as ovarian cystectomy and ectopic pregnancy (Group III). Those in Table 1 Characteristics of the three study groups Group I (TAHBSO) (n = 33) Age’(STD) Education (%) None Primary Secondary Tertiary Employed (%) Salary’*b (STD) Family incomea+b (STD)
46.0 (6.8) 6 (18.2) 18 (54.5) 9 (27.3) 0 17 (51.5) 4064.7 1 (2389.18) 8395.95 (4269.47)
“Presented as mean values. bPresented in Hong Kong dollars in parentheses.
Group II (TAH) (ii = 33) 39.9 (7.7) 4 (12.2) 17 (51.5) 11 (33.3) I (3.1) 15 (45.4) 3566.67 (1537.39) 8328.13 (4004.14)
Group 111 (Other) (n = 13) 36.1 (5.6) I (7.8) 6 (46.1) 6 (46.1) 0 7 (53.8) 4042.86 (1345.74) 8461.54 (1272.75)
7 I2 I8 I5
I4 8
Insomnia Headaches Memory disturbance Irritability
Anxiety Urinary tract disturbance
I 8
8 3 I I
2 6
5 7
II 3 9 7
8 6
Final
8 IO
6 9 6 II
2 3
Preop
II
3 4
9 I 1 2
3 9
Postop
symptoms
3 I
4 4 5 0
0 3
Final
the oophorectomized
who developed
(TAH) (n = 33)
Group
between
of patients
symptoms
Numbers in the Postop and Final columns represent the number the number of patients with symptoms preceding surgery.
2 4
Preop
(n = 33)
Postop
of acute menopausal
Group I (TAHBSO)
of the development
Hot flushes Sweating
Table 2 A comparison
following
surgery.
6 6
4 4 6 6
0 0
Preop
(n = 13)
Numbers
I 2
2 2 0 0
I 4
Postop
groups
Group III (Laparotomy)
and the two control
in the Preop column
2 2
2 2 2 3
2 0
Final
represent
178
C.J. Haines et al. /Maturitas I8 (1994)
175-181
Group II were examined separately as it has been suggested that a hysterectomy alone may still interfere with ovarian blood supply and therefore potentially result in symptoms which would not be present in those women having had a laparotomy for other indications [6]. The women were not told that this study was specifically related to the menopause, but rather that it was a survey to investigate any delayed effects of their operative treatment. The same questions were repeated postoperatively on the day of hospital discharge and again no sooner than their 6 week postoperative outpatient visit. At the final visit all subjects were invited to volunteer any additional symptoms which had developed following surgery. For the analysis of data involving observations on a continuous scale, I-tests were performed. For data involving counts, Chi-square or Fisher’s exact test was used. For data analysed with the Chi-square or Fisher’s exact test, some grouping of the data was necessary. For all tests, P < 0.05 was considered significant. 3. Results The survey group comprised 33 women in Group I, 33 in Group II and 13 in Group III. All women included in the study were interviewed on the preoperative day and again between days 3 and 17 postoperatively (mean 6.5 days). The final interview was conducted on or after the 6-week postoperative follow-up (mean 75.3 days, range 25-363). A summary of the responses is presented in Table 2. The mean age of the women in Group I was greater than that in either of the other two groups (P = 0.001). There was no difference in the level of education, employment, salary nor family income between the three groups. Pre-existent symptoms were present in all of the three groups. There was no difference in the frequency of vasomotor symptoms between the three groups at the preoperative survey, but those subjects in Groups I and II complained of memory disturbances more frequently than those in Group III (P = 0.004). In those with hot flushes, these were reported at a mean frequency of 1S/h and a duration of 1.3 min. Headaches, memory disturbances, irritability and anxiety were more commonly reported preoperatively in all groups than at the postoperative or final interview, but these differences were not significant. At the postoperative interview (conducted before hospital discharge), there were no differences in the development of vasomotor nor other symptoms between the three operative groups. Hot flushes and sweating appeared in 2/33 (6.1%) and 6/33 (18.2%), respectively, of those women in Group I, 3/33 (9.1%) and 9/33 (27.3%) in Group II and l/l3 (7.7%) and 4/13 (30.8%) of those in Group III. Hot flushes occurred with a mean frequency of 2.3/h and lasted 2.2 min. At the final interview, hot flushes and sweating had developed more frequently in Group I than in Group II (P = 0. 001, P = 0.023). Whilst sweating was more frequent amongst those in Group I compared with Group III subjects (P = 0.015), there was no difference in the reporting of other symptoms between these two groups. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%), respectively, in Group I, O/33 and 3/33 (9.1%) in Group II and in 2/13 (15.4%) and 0113 in Group III. There was a mean of 3.8 hot flushes per hour, lasting 1.4 min. Insomnia, memory disturbances, irritability and urinary disorders were also more
C.J. Haines et al. lh4aturitas 18 (1994)
175-181
179
common amongst women in Group I than those in Group II (P = 0.013, P = 0.003, P = 0.001, P = 0.024, respectively). There was no consistent pattern of response regarding the development of any other symptoms following surgery. When comparing the two control groups (Groups II and III), there was a greater incidence of hot flushes and irritability after 6 or more weeks in those subjects having had a laparotomy than in those with a TAH (P = 0.025, P = 0.001). This difference was not present at the immediate postoperative interview. 4. Discussion Previous surveys conducted amongst Caucasian women undergoing a spontaneous menopause have indicated that hot flushes and night sweats are associated with the onset of menopause and occur in the majority of women. In a study of 100 patients who had undergone a surgical menopause, 94 experienced vasomotor symptoms as the first climacteric symptom, with 50 developing this problem before hospital discharge and 84 within 6 weeks of operation [5]. In this study, apart from age, there was no difference in social characteristics between the three groups. The fact that women in Group I were older meant that TAHBSO was more likely to be performed than hysterectomy with conservation of the ovaries. There were no differences in the incidence of vasomotor symptoms between the groups at the preoperative interview. The fact that headaches, memory disturbances, irritability and anxiety were more frequent complaints preoperatively in all groups may have been a reflection of the level of anxiety which may have been expected of a patient on the day preceding a surgical procedure. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%) women, respectively, following a surgical menopause. (Hot flushes and sweating were already present in 2 and 4 women, respectively, before surgery.) Whilst these symptoms occurred in a significantly greater number of women in this group than amongst those who had undergone a laparotomy for other indications, the reporting of these symptoms occurred much less frequently than has been documented in Caucasian women. The division of the controls into two subgroups rather than one may have been unnecessary. There was a significantly greater incidence of vasomotor symptoms in the oophorectomized women compared with either of the control groups, suggesting that those women who had a hysterectomy alone did not suffer significant interference with ovarian blood supply. Whilst blood was taken in the majority of cases to confirm that those having had a TAHBSO had become menopausal, there were not enough cases in the control groups with complete blood results to allow a comparison of hormonal outcome between those patients having hysterectomy and those with a laparotomy for other indications. The fact that there was no difference in the onset of hot flushes between those having TAHBSO and the group having a laparotomy may be a reflection of the small numbers included in the latter group. The incidence of vasomotor symptoms reported at the interview before hospital discharge may have been an overestimate. The incidence of sweating was higher in all groups than that of hot flushes and may have been due to the presence of low grade fever which frequently accompanies major surgery. Hot flushes, however, were
180
C.J. Haines et al. /Maturitas 18 (1994)
175-181
not usually reported at the interview conducted before discharge, which was contrary to our experience with Caucasians and also to the reported experience of others [71. A number of factors may influence the frequency with which postmenopausal women use HRT. These include the attitude of the medical practitioner, the preference of the patient, the presence of any contraindications and the severity of symptoms. Various studies have reported on the effect of cultural factors on the frequency and severity of climacteric symptoms. Apart from the cessation of menses, relatively few symptoms were present amongst Rajput caste women in India [8] and there were similar findings in a study of Arabian women [9]. Of those populations which are in the same region as Hong Kong, Japanese women have very few symptoms [4], but 69% of Thai women in Bangkok reported hot flushes and other climacteric symptoms were also common [3]. In our own population, ongoing research suggests that whilst women in Hong Kong are familiar with the fact that menstruation ceases at around 50 years of age, there is very little knowledge about associated short- and long-term effects of the menopause and also almost no knowledge of available treatment. This prospective study was biased by the leading nature of the questioning for the presence of acute menopausal symptoms and also by the selection of a surgical rather than a naturally occurring menopause. Despite the introduction of this bias, the symptoms most commonly suffered by postmenopausal Caucasian women were reported much less frequently in this population. Some women reported severe vasomotor symptoms, but the numbers were very few. We remain uncertain why there was a low incidence of symptoms in this study group, or why cross-cultural differences exist. The study design would have been more likely to result in an overestimate of the occurrence of symptoms than an underestimate. Similarly, climatic conditions would have been unlikely to have affected the results as the study was conducted in summer, when sweating may have been more frequent. This relative absence of symptoms is of relevance to the provision of satisfactory health care to postmenopausal women in Hong Kong and in other countries where symptoms are infrequent. The combination of a low incidence of symptoms accompanied by little knowledge of the potentially serious long-term sequelae of oestrogen deficiency means that many women in these areas who could benefit from hormone replacement therapy will not receive treatment. 5. References I
2 3 4 5
McKinley SM, Jeffrys M. The menopausal syndrome. Br J Prev Sot Med 1974; 28: 108-l 15. Hagstad A, Janson PO. The epidemiology of climacteric symptoms. Acta Obstet Gynecol Stand Suppl 1986; 134: 59-65. Sukwatana P, Meekhangvan J, Tamrongterakul Y, Tanapat Y, Asavarait S, Boonjitrpimon P. Menopausal symptoms among Thai women in Bangkok. Maturitas 1991; 13: 217-228. Lock M. Ambiguities of aging: Japanese experience and perceptions of menopause. Cult Med Psychiatry 1986; 10; 23-46. Beyene Y. Cultural significance and physiological manifestations of menopause. A biocultural analysis. Cult Med Psychiatry 1986; IO: 47-71.
C.J. Haines et al. /Maturitas
6
I 8 9
18 (1994)
175-181
181
Whitehead M, Godfree V. Hormone Replacement Therapy - Your Questions Answered. First Edition. Edinburgh: Churchill Livingstone, 1992. Chakravarti S, Collins WP, Newton JR, Studd JWW. Endocrine changes and symptomatology after oophorectomy in premenopausal women. Br J Obstet Gynaecol 1977; 84: 769-775. Flint MP. Sociology and anthropology of the menopause. In: Van Keep PA, Serr DM, Greenblatt RB, eds. Female and male climacteric, Lancaster: MTP Press, 1979; l-8. Maoz B. The perception of the menopause in five ethnic groups in Israel (Thesis), Leiden, 1973.