- Email: [email protected]
Associated factors with urogenital score in natural and surgical menopause
Maturitas 52 (2005) 65–69
Associated factors with urogenital score in natural and surgical menopause Hikmet Hassaa , H. Mete Tanira,∗ , Atilla Yildirima , Tanser Sensesa , Tufan Ogea , Fezan Sahin Mutlub a
Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Meselik Kampusu, 26480 Eskisehir, Turkey b Department of Biostatistics, Faculty of Medicine, Osmangazi University, Meselik Kampusu, 26480 Eskisehir, Turkey Received 12 November 2004; received in revised form 18 December 2004; accepted 22 December 2004
Abstract Objective: To anticipate the factors associated with urogenital symptoms in both natural and surgical menopause. Methods: A retrospective analysis was performed comprising 267 cases with spontaneous menopause and 87 surgical menopause cases without any use of hormone replacement therapy. Sociodemographic characteristics, reproductive and medical history, urogenital scale and psychological subscale of Greene Climacteric Scale were assessed and correlated with the age of menopause, time past since last menstrual period, parity, body mass index (BMI), mode of delivery among two groups. Results: Mean age of women enrolled to the study were 46.8 ± 0.3 years and 44.4 ± 0.25 years, for natural and surgical menopause cases, respectively. Mean parity had no correlation with urogenital scale in two groups. However, a positive correlation was apparent between the time since last menstrual period, psychological subscore of Green Climacteric Scale and urogenital score in both women with natural and surgical menopause. BMI was negatively correlated with urogenital score among two groups (rp = −0.85, p = 0.04). Conclusions: Intensity and frequency of urogenital symptoms and climacteric complaints as expressed in the Greene Climacteric Scale increase during menopausal transition. Care should be taken to ameliorate the quality of life (QOL) and to confront these problems in post-menopausal women. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Menopause; Urogenital score; Greene Climacteric Scale; Quality of life
1. Introduction
∗ Corresponding author. Tel.: +90 222 2398412; fax: +90 222 2398412. E-mail address: [email protected] (H.M. Tanir).
Vaginal, urethral and urinary bladder tissues are known to be sensitive to estrogenic stimulus. In postmenopausal state, circulating estrogen concentration is significantly lower than pre-menopausal period and
0378-5122/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2004.12.005
66
H. Hassa et al. / Maturitas 52 (2005) 65–69
because of this estrogenic deprivation some anatomical, physiological and psychological changes occur in women [1,2]. One-third of women over the age of 60 complain about urogenital estrogen insufficiency symptoms. This ratio is as high as two-third in women over 75 [3,4]. These symptoms can really have an important impact in daily, social and sexual life of postmenopausal women. As a measure for climacteric symptoms and complaints, Greene Climacteric Scale has been introduced to meet the present accepted standards for psychological, somatic and vasomotor symptoms [4]. This study aimed to find out associated factors with urogenital symptoms in both natural and surgical menopause and secondarily, to evaluate the quality of life of women in the climacteric period with the use of an individually developed questionnaire such as Greene Climacteric Scale.
2. Material and methods
Table 1 Items of the Greene Climacteric Scale (5)a Symptom (1) Heart beating quickly or strong (2) Feeling tense or nervous (3) Difficulty in sleeping (4) Excitable (5) Attacks of panic (6) Difficulty in concentrating (7) Feeling tired or lacking in energy (8) Loss of interest in most things (9) Feeling unhappy or distressed (10) Crying spells (11) Irritability (12) Feeling dizzy or faint (13) Pressure or tightness in head and body (14) Parts of body feel numb or tingling (15) Headaches (16) Muscle and joint pains (17) Loss of feeling in hands or feet (18) Breathing difficulties (19) Hot flushes (20) Sweating at night (21) Loss of interest in sex a
This prospective study was conducted among postmenopausal women visiting the menopause clinic in a university hospital in Central Anatolian Region of Turkey, during the time period from August 2000 and April 2003. A total number of 485 post-menopausal women (349 natural + 136 surgical menopause) were recruited during this period. Of those cases, 267 natural menopause and 87 surgical menopause cases were received the Greene Climacteric Scale and enrolled into the study. Women with current or past history of systemic or local hormone replacement therapy (HRT) were excluded from the study. The women with spontaneous menopause had no bleeding episode within the last 12 months and their serum FSH levels were >40 mIU/ml. Those cases with a past history of total abdominal hysterectomy and bilateral salpingo-oopherectomy operations due to benign gynecological conditions such as myoma uteri, benign adnexal mass, endometrial hyperplasia/polyp, endometriosis or intractable chronic pelvic pain constituted the surgical menopause group. Data including sociodemographic characteristics, reproductive and medical history, urogenital scale and psychological subscale of Greene Climacteric scale were collected in the form of structured interview [5].
Greene JG. Constructing a standard climacteric scale. Maturitas 1998;29:25–31.
The Greene Climacteric Scale measured a total of 21 symptoms described in Table 1. Each symptom is rated by the woman herself according to its severity using a four-point rating scale: not-at-all (0); a little (1); quite a bit (2); extremely (3). As shown in Table 1, symptoms 1–11 address psychological symptoms divided in a measure of anxiety (a sum of symptoms 1–6) and of depression (a sum of symptoms 7–11). Somatic symptoms are addressed in symptoms 12–18 and vasomotor symptoms in symptom 19 and 20. Symptom 21 is a probe for sexual dysfunction. The total Greene Climacteric Score is the sum of all 21 scores. Urogenital scale was composed of vaginal and urinary subscales. In vaginal subscale, vaginal pain, dyspareunia, itching, discharge, burning, dryness and postcoital bleeding within the last 3 months were requested to be answered as “none, mild, moderate and severe” and in urinary subscale dysuria, frequency, nocturia and incontinence were asked and coded as “none, mild, moderate and severe”. According to the answers from the patients, they were scored between 0 and 3 points. Based on the sum of these values, vaginal and urinary subscores and total urogenital score were assessed. Age at menopause, time past since last menstrual period,
H. Hassa et al. / Maturitas 52 (2005) 65–69
67
Table 2 Various parameters in natural menopause and their relationship with urogenital score Parameter
n
Mean ± S.E.M.
Parity (n) BMI (kg/m2 ) Menopausal age (years) 267 Time since becoming post-menopausal (years) Greene psychological subscore
267 267
2.5 27.4 46.8 3.3 10.4
267 267
± ± ± ± ±
0.1 0.2 0.3 0.3 0.3
Correlation results NS rp = −0.85, p = 0.04 NS rp = 0.09, p = 0.03 rp = 0.397, p = 0.001
rp : Pearson correlation coefficient; NS: not significant.
parity, body mass index (BMI) [weight (kg)/height2 (m2 )], mode of delivery and psychological state, as measured in Greene Climacteric Scale, were the parameters investigated in each group. Statistical analysis was performed by using SPSS 10.0 (Chicago, IL, USA). Pearson rank correlation was performed for continuous variables. Power analysis of the study was assessed by using NCSS 2000 and PASS 2000 Package Programme. Mean values were expressed as mean ± standard error of mean (S.E.M.) and were compared by the independent Student’s t-test. A p-value of <0.05 was considered statistically significant.
3. Results Mean ages at menopause were 46.8 ± 0.30 years and 44.4 ± 0.25 years and time since becoming postmenopausal were 3.3 ± 0.3 years and 4.3 ± 0.4 years in
natural menopause and surgical menopause cases, respectively. For natural and surgical menopause cases, 3.8% and 6.4% of patients had no delivery respectively. Meanwhile, 3.8% of the natural menopause and 3.8% of surgical menopause cases gave a history of caesarean section delivery, while 92.4 % and 88.6% had vaginal delivery, respectively. Mean BMI and parity of natural and surgical menopause cases were shown in Tables 2 and 3. These parameters had no correlation with urogenital scale in two groups. As shown in both Tables 2 and 3, the time since becoming postmenopausal and psychological subscore of Greene Climacteric Scale were found to be positively correlated with urogenital score in natural and surgical menopause cases. Although BMI was negatively correlated in both groups, menopausal age had a negative correlation with urogenital score only in surgical menopausal patients (rp = −0.28, p = 0.04). As shown in Table 4, natural menopause group had mean vaginal, urinary subscores and total urogenital
Table 3 Various parameters in surgical menopause and their relationship with urogenital score Parameter
n
Mean ± S.E.M.
Parity (n) BMI (kg/m2 ) Menopausal age (years) Time since becoming post-menopausal (years) Greene psychological subscore
267 267 267 267 267
2.7 28.8 44.4 4.3 9.4
± ± ± ± ±
0.1 0.9 0.3 0.4 0.8
Correlation results NS rp = −0.28, p = 0.04 rp = −0.34 p = 0.01 rp = 0.36, p = 0.01 rp = 0.392, p = 0.005
NS: non-significant; rp : Pearson correlation coefficient. Table 4 Comparisons of mean urinary, vaginal subscores and total urogenital scores (ranging 0–3 points) in natural and surgical menopause groups
Urinary subscore Vaginal subscore Total urogenital score NS: not significant.
Natural menopause (mean ± S.E.M.)
Surgical menopause (mean ± S.E.M.)
Statistical result
2.53 ± 0.1 1.93 ± 0.1 2.46 ± 0.2
2.50 ± 0.1 1.76 ± 0.1 2.24 ± 0.2
NS NS NS
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H. Hassa et al. / Maturitas 52 (2005) 65–69
scores as 1.93 ± 0.1, 2.53 ± 0.1 and 4.46 ± 0.2, respectively. Those scores were 1.76 ± 0.1; 2.50 ± 0.1 and 4.24 ± 0.2 in surgical menopause cases, respectively, that were not statistically different among two aforementioned groups (p > 0.05).
4. Discussion On the basis of the aforementioned findings, it became obvious that post-menopausal women with natural and surgical menopause enrolled into this study were not representative of true population of women with natural and surgical menopause in Turkey. Given the fact that mean age of menopause in Turkey is around 47 years, five years earlier than the average age at menopause in the general literature, these ages presented in the present study raised some concerns about the representativeness of that group. However, of the total number of 485 post-menopausal women only 354 cases (267 natural and 87 surgical menopause) were recruited for this study. Based on the inclusion criteria of this study, women with any current or past use of HRT were excluded from that study. In addition, some cases were lost during follow-up. Some cases were called for the study entry but were unavailable at the questionnaire day. Therefore, should all the cases were included into the study, irrespective of use of any form of HRT, mean ages of cases with natural menopause and surgical menopause would have been 50.1 ± 0.2 years and 49.0 ± 0.3 years, respectively. Because of these limitations, the sample size and age distributions shown in this study could not be extrapolated for the whole population. Another limitation of the study was inconsistency of test power (1 − β) values of statistical results in some comparisons. For instance, in Table 3, assuming type II error (α-value) of 0.05: comparisons for BMI (power: 0.99, β: 0.01), age at menopause (power: 0.99, β: 0.01), time past since last menstrual period (power: 0.99, β: 0.012) and Greene psychological subscore power 1.0, β: 0). However, in Table 4, the power of the study was low, ranging from 0.05 to 0.17 for β-values of 0.80–0.95. Hence, it is obvious that there is a need for re-evaluating of those results on a large data set in the future. Urogenital atrophy due to estrogen deficiency starts in early years of menopause. However, unlike those
symptoms related with the neurovegetative system, urogenital system-related complaints tend to occur later in the post-menopausal period, usually 5–6 years after the menopause [6]. Hence, symptoms and signs of the urogenital estrogen deficiency syndrome occur relatively late in a women’s life when endogenous estrogen levels decline. At age 60 and above symptoms are common and progress with advancing age. The first and most common complaint is vaginal dryness, but symptoms of lost control of micturition as well as urge incontinence are also frequent. Recurrent infections of the lower urinary tract are common, as well as dyspareunia and a sensation of burning and itching [3,4,7]. Although these symptoms may be troublesome for these women they are usually underestimated by care givers. As the expectancy of life increases, managing with these urogenital symptoms will assist the physicians to ameliorate QOL measurements of these post-menopausal women. Although mean duration of post-menopausal period is short in both groups in our study (3.3 ± 0.3 and 4.3 ± 0.4 years in natural menopause and surgical menopause), our results showed that duration of postmenopausal period was mildly correlated with urogenital score. Menopausal age of women in surgical menopause group was also found to be negatively correlated with total urogenital score. This may be due to earlier age at menopause (46.8 ± 0.30 years and 44.4 ± 0.25 years, respectively) and thus longer duration of menopause in that group. Based on the aforementioned data of the current study, BMI of cases was negatively correlated with the total urogenital score. We did not evaluate the individual parameters in the total urogenital scores such as dyspareunia, frequency urgency, incontinence, etc. . .. Pastore et al. [8], through a cross-sectional analysis based on 98,705 women enrolled in the US-based Women’s Health Initiative observational study and clinical trials found an elevated prevalence and severity of urogenital symptoms among women who are Hispanic, obese, and/or diabetic. Furthermore, There are studies in the literature showing increased urinary incontinence among women with high BMI [9]. According to another recent case-control study, the risk of all types of urinary incontinence was increased in women with higher BMI, with a history of hysterectomy [10]. With regard to anatomical changes with different modes of delivery, vaginal and urinary subscales were
H. Hassa et al. / Maturitas 52 (2005) 65–69
not found to be different in both groups in cases delivered via caesarean section or vaginal route. In addition to anatomical changes, neurological changes (possible urinary denervation during hysterectomy) also can be expected to affect urogenital symptomatology among natural and surgical menopause cases. But there was no association found in our study. It is reported that loss of libido, orgasmic dysfunction, decreased clitoral arousal and decreased frequency of sexual intercourse can be seen in the postmenopausal period [9]. Other than neurovegetative changes, vulvovaginal atrophy may also cause decreased vaginal lubrication and fear of painful coital activity and possible post-coital bleeding can cause women stay away from sexual activity. Urinary symptoms also may add to this negative attitude. These physiological changes provoke anxiety and depressive symptoms and therefore, psychosexual problems ensue [11]. Our results also show this important correlation in both vaginal and urinary subscales. To conclude, as duration of post-menopausal state increases urogenital symptoms begin to affect the women’s lives and these symptoms are in close relation with anxious and depressive psychological state. Hence, physicians should deal with these symptoms and do their best to alleviate those complaints in an aim to ameliorate QOL of post-menopausal women.
69
References [1] Sherman BM, Korenman SG. Hormonal characteristics of the human menstrual cycle throughout the reproductive life. J Clin Invest 1975;65:699–706. [2] Judd HL. Hormonal dynamics associated with the menopause. Clin Obstet Gynaecol 1976;19:775–88. [3] Iosif CS, Bekassy Z. Prevalence of genitourinary symptoms in late menopause. Acta Obstet Gynaecol Scand 1984;63:257–60. [4] Samsioe G. Medical and surgical strategies for treating urogynecological disorders. Int J Fertil Menopausal Stud 1996;41:136–41. [5] Greene JG. Constructing a standard climacteric scale. Maturitas 1998;29:25–31. [6] Samsioe G. Medical and surgical strategies for treating urogynecological disorders. Int J Fertil Menopausal Stud 1996;41(2):136–41. [7] Iosif CS, Bekassy Z. Prevalence of genitourinary symptoms in late menopause. Acta Obstet Gynaecol Scand 1984;63:257–60. [8] Pastore LM, Carter RA, Hulka BS, Wells E. Self-reported urogenital symptoms in postmenopausal women: women’s health initiative. Maturitas 2004;49(4):292–303. [9] Brown JS, Seeley DG, Fong J, Black DM, Ensrud KE, Grady D. Urinary incontinence in older women: who is at risk? Obstet Gynaecol 1996;87:715–21. [10] Parazzini F, Chiaffarino F, Lavezzari M, Giambanco V, VIVA Study Group. Risk factor for stress, urge or mixed urinary incontinence in Italy. BJOG 2003;110(10):927–33. [11] Barentsen R, van der Weijer PHM, van Gend S, Foekema H. Climacteric symptoms in a representative Dutch population sample as measured with the Greene Climacteric Scale. Maturitas 2001;38:123–8.
Associated factors with urogenital score in natural and surgical menopause Hikmet Hassaa , H. Mete Tanira,∗ , Atilla Yildirima , Tanser Sensesa , Tufan Ogea , Fezan Sahin Mutlub a
Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Meselik Kampusu, 26480 Eskisehir, Turkey b Department of Biostatistics, Faculty of Medicine, Osmangazi University, Meselik Kampusu, 26480 Eskisehir, Turkey Received 12 November 2004; received in revised form 18 December 2004; accepted 22 December 2004
Abstract Objective: To anticipate the factors associated with urogenital symptoms in both natural and surgical menopause. Methods: A retrospective analysis was performed comprising 267 cases with spontaneous menopause and 87 surgical menopause cases without any use of hormone replacement therapy. Sociodemographic characteristics, reproductive and medical history, urogenital scale and psychological subscale of Greene Climacteric Scale were assessed and correlated with the age of menopause, time past since last menstrual period, parity, body mass index (BMI), mode of delivery among two groups. Results: Mean age of women enrolled to the study were 46.8 ± 0.3 years and 44.4 ± 0.25 years, for natural and surgical menopause cases, respectively. Mean parity had no correlation with urogenital scale in two groups. However, a positive correlation was apparent between the time since last menstrual period, psychological subscore of Green Climacteric Scale and urogenital score in both women with natural and surgical menopause. BMI was negatively correlated with urogenital score among two groups (rp = −0.85, p = 0.04). Conclusions: Intensity and frequency of urogenital symptoms and climacteric complaints as expressed in the Greene Climacteric Scale increase during menopausal transition. Care should be taken to ameliorate the quality of life (QOL) and to confront these problems in post-menopausal women. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Menopause; Urogenital score; Greene Climacteric Scale; Quality of life
1. Introduction
∗ Corresponding author. Tel.: +90 222 2398412; fax: +90 222 2398412. E-mail address: [email protected] (H.M. Tanir).
Vaginal, urethral and urinary bladder tissues are known to be sensitive to estrogenic stimulus. In postmenopausal state, circulating estrogen concentration is significantly lower than pre-menopausal period and
0378-5122/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2004.12.005
66
H. Hassa et al. / Maturitas 52 (2005) 65–69
because of this estrogenic deprivation some anatomical, physiological and psychological changes occur in women [1,2]. One-third of women over the age of 60 complain about urogenital estrogen insufficiency symptoms. This ratio is as high as two-third in women over 75 [3,4]. These symptoms can really have an important impact in daily, social and sexual life of postmenopausal women. As a measure for climacteric symptoms and complaints, Greene Climacteric Scale has been introduced to meet the present accepted standards for psychological, somatic and vasomotor symptoms [4]. This study aimed to find out associated factors with urogenital symptoms in both natural and surgical menopause and secondarily, to evaluate the quality of life of women in the climacteric period with the use of an individually developed questionnaire such as Greene Climacteric Scale.
2. Material and methods
Table 1 Items of the Greene Climacteric Scale (5)a Symptom (1) Heart beating quickly or strong (2) Feeling tense or nervous (3) Difficulty in sleeping (4) Excitable (5) Attacks of panic (6) Difficulty in concentrating (7) Feeling tired or lacking in energy (8) Loss of interest in most things (9) Feeling unhappy or distressed (10) Crying spells (11) Irritability (12) Feeling dizzy or faint (13) Pressure or tightness in head and body (14) Parts of body feel numb or tingling (15) Headaches (16) Muscle and joint pains (17) Loss of feeling in hands or feet (18) Breathing difficulties (19) Hot flushes (20) Sweating at night (21) Loss of interest in sex a
This prospective study was conducted among postmenopausal women visiting the menopause clinic in a university hospital in Central Anatolian Region of Turkey, during the time period from August 2000 and April 2003. A total number of 485 post-menopausal women (349 natural + 136 surgical menopause) were recruited during this period. Of those cases, 267 natural menopause and 87 surgical menopause cases were received the Greene Climacteric Scale and enrolled into the study. Women with current or past history of systemic or local hormone replacement therapy (HRT) were excluded from the study. The women with spontaneous menopause had no bleeding episode within the last 12 months and their serum FSH levels were >40 mIU/ml. Those cases with a past history of total abdominal hysterectomy and bilateral salpingo-oopherectomy operations due to benign gynecological conditions such as myoma uteri, benign adnexal mass, endometrial hyperplasia/polyp, endometriosis or intractable chronic pelvic pain constituted the surgical menopause group. Data including sociodemographic characteristics, reproductive and medical history, urogenital scale and psychological subscale of Greene Climacteric scale were collected in the form of structured interview [5].
Greene JG. Constructing a standard climacteric scale. Maturitas 1998;29:25–31.
The Greene Climacteric Scale measured a total of 21 symptoms described in Table 1. Each symptom is rated by the woman herself according to its severity using a four-point rating scale: not-at-all (0); a little (1); quite a bit (2); extremely (3). As shown in Table 1, symptoms 1–11 address psychological symptoms divided in a measure of anxiety (a sum of symptoms 1–6) and of depression (a sum of symptoms 7–11). Somatic symptoms are addressed in symptoms 12–18 and vasomotor symptoms in symptom 19 and 20. Symptom 21 is a probe for sexual dysfunction. The total Greene Climacteric Score is the sum of all 21 scores. Urogenital scale was composed of vaginal and urinary subscales. In vaginal subscale, vaginal pain, dyspareunia, itching, discharge, burning, dryness and postcoital bleeding within the last 3 months were requested to be answered as “none, mild, moderate and severe” and in urinary subscale dysuria, frequency, nocturia and incontinence were asked and coded as “none, mild, moderate and severe”. According to the answers from the patients, they were scored between 0 and 3 points. Based on the sum of these values, vaginal and urinary subscores and total urogenital score were assessed. Age at menopause, time past since last menstrual period,
H. Hassa et al. / Maturitas 52 (2005) 65–69
67
Table 2 Various parameters in natural menopause and their relationship with urogenital score Parameter
n
Mean ± S.E.M.
Parity (n) BMI (kg/m2 ) Menopausal age (years) 267 Time since becoming post-menopausal (years) Greene psychological subscore
267 267
2.5 27.4 46.8 3.3 10.4
267 267
± ± ± ± ±
0.1 0.2 0.3 0.3 0.3
Correlation results NS rp = −0.85, p = 0.04 NS rp = 0.09, p = 0.03 rp = 0.397, p = 0.001
rp : Pearson correlation coefficient; NS: not significant.
parity, body mass index (BMI) [weight (kg)/height2 (m2 )], mode of delivery and psychological state, as measured in Greene Climacteric Scale, were the parameters investigated in each group. Statistical analysis was performed by using SPSS 10.0 (Chicago, IL, USA). Pearson rank correlation was performed for continuous variables. Power analysis of the study was assessed by using NCSS 2000 and PASS 2000 Package Programme. Mean values were expressed as mean ± standard error of mean (S.E.M.) and were compared by the independent Student’s t-test. A p-value of <0.05 was considered statistically significant.
3. Results Mean ages at menopause were 46.8 ± 0.30 years and 44.4 ± 0.25 years and time since becoming postmenopausal were 3.3 ± 0.3 years and 4.3 ± 0.4 years in
natural menopause and surgical menopause cases, respectively. For natural and surgical menopause cases, 3.8% and 6.4% of patients had no delivery respectively. Meanwhile, 3.8% of the natural menopause and 3.8% of surgical menopause cases gave a history of caesarean section delivery, while 92.4 % and 88.6% had vaginal delivery, respectively. Mean BMI and parity of natural and surgical menopause cases were shown in Tables 2 and 3. These parameters had no correlation with urogenital scale in two groups. As shown in both Tables 2 and 3, the time since becoming postmenopausal and psychological subscore of Greene Climacteric Scale were found to be positively correlated with urogenital score in natural and surgical menopause cases. Although BMI was negatively correlated in both groups, menopausal age had a negative correlation with urogenital score only in surgical menopausal patients (rp = −0.28, p = 0.04). As shown in Table 4, natural menopause group had mean vaginal, urinary subscores and total urogenital
Table 3 Various parameters in surgical menopause and their relationship with urogenital score Parameter
n
Mean ± S.E.M.
Parity (n) BMI (kg/m2 ) Menopausal age (years) Time since becoming post-menopausal (years) Greene psychological subscore
267 267 267 267 267
2.7 28.8 44.4 4.3 9.4
± ± ± ± ±
0.1 0.9 0.3 0.4 0.8
Correlation results NS rp = −0.28, p = 0.04 rp = −0.34 p = 0.01 rp = 0.36, p = 0.01 rp = 0.392, p = 0.005
NS: non-significant; rp : Pearson correlation coefficient. Table 4 Comparisons of mean urinary, vaginal subscores and total urogenital scores (ranging 0–3 points) in natural and surgical menopause groups
Urinary subscore Vaginal subscore Total urogenital score NS: not significant.
Natural menopause (mean ± S.E.M.)
Surgical menopause (mean ± S.E.M.)
Statistical result
2.53 ± 0.1 1.93 ± 0.1 2.46 ± 0.2
2.50 ± 0.1 1.76 ± 0.1 2.24 ± 0.2
NS NS NS
68
H. Hassa et al. / Maturitas 52 (2005) 65–69
scores as 1.93 ± 0.1, 2.53 ± 0.1 and 4.46 ± 0.2, respectively. Those scores were 1.76 ± 0.1; 2.50 ± 0.1 and 4.24 ± 0.2 in surgical menopause cases, respectively, that were not statistically different among two aforementioned groups (p > 0.05).
4. Discussion On the basis of the aforementioned findings, it became obvious that post-menopausal women with natural and surgical menopause enrolled into this study were not representative of true population of women with natural and surgical menopause in Turkey. Given the fact that mean age of menopause in Turkey is around 47 years, five years earlier than the average age at menopause in the general literature, these ages presented in the present study raised some concerns about the representativeness of that group. However, of the total number of 485 post-menopausal women only 354 cases (267 natural and 87 surgical menopause) were recruited for this study. Based on the inclusion criteria of this study, women with any current or past use of HRT were excluded from that study. In addition, some cases were lost during follow-up. Some cases were called for the study entry but were unavailable at the questionnaire day. Therefore, should all the cases were included into the study, irrespective of use of any form of HRT, mean ages of cases with natural menopause and surgical menopause would have been 50.1 ± 0.2 years and 49.0 ± 0.3 years, respectively. Because of these limitations, the sample size and age distributions shown in this study could not be extrapolated for the whole population. Another limitation of the study was inconsistency of test power (1 − β) values of statistical results in some comparisons. For instance, in Table 3, assuming type II error (α-value) of 0.05: comparisons for BMI (power: 0.99, β: 0.01), age at menopause (power: 0.99, β: 0.01), time past since last menstrual period (power: 0.99, β: 0.012) and Greene psychological subscore power 1.0, β: 0). However, in Table 4, the power of the study was low, ranging from 0.05 to 0.17 for β-values of 0.80–0.95. Hence, it is obvious that there is a need for re-evaluating of those results on a large data set in the future. Urogenital atrophy due to estrogen deficiency starts in early years of menopause. However, unlike those
symptoms related with the neurovegetative system, urogenital system-related complaints tend to occur later in the post-menopausal period, usually 5–6 years after the menopause [6]. Hence, symptoms and signs of the urogenital estrogen deficiency syndrome occur relatively late in a women’s life when endogenous estrogen levels decline. At age 60 and above symptoms are common and progress with advancing age. The first and most common complaint is vaginal dryness, but symptoms of lost control of micturition as well as urge incontinence are also frequent. Recurrent infections of the lower urinary tract are common, as well as dyspareunia and a sensation of burning and itching [3,4,7]. Although these symptoms may be troublesome for these women they are usually underestimated by care givers. As the expectancy of life increases, managing with these urogenital symptoms will assist the physicians to ameliorate QOL measurements of these post-menopausal women. Although mean duration of post-menopausal period is short in both groups in our study (3.3 ± 0.3 and 4.3 ± 0.4 years in natural menopause and surgical menopause), our results showed that duration of postmenopausal period was mildly correlated with urogenital score. Menopausal age of women in surgical menopause group was also found to be negatively correlated with total urogenital score. This may be due to earlier age at menopause (46.8 ± 0.30 years and 44.4 ± 0.25 years, respectively) and thus longer duration of menopause in that group. Based on the aforementioned data of the current study, BMI of cases was negatively correlated with the total urogenital score. We did not evaluate the individual parameters in the total urogenital scores such as dyspareunia, frequency urgency, incontinence, etc. . .. Pastore et al. [8], through a cross-sectional analysis based on 98,705 women enrolled in the US-based Women’s Health Initiative observational study and clinical trials found an elevated prevalence and severity of urogenital symptoms among women who are Hispanic, obese, and/or diabetic. Furthermore, There are studies in the literature showing increased urinary incontinence among women with high BMI [9]. According to another recent case-control study, the risk of all types of urinary incontinence was increased in women with higher BMI, with a history of hysterectomy [10]. With regard to anatomical changes with different modes of delivery, vaginal and urinary subscales were
H. Hassa et al. / Maturitas 52 (2005) 65–69
not found to be different in both groups in cases delivered via caesarean section or vaginal route. In addition to anatomical changes, neurological changes (possible urinary denervation during hysterectomy) also can be expected to affect urogenital symptomatology among natural and surgical menopause cases. But there was no association found in our study. It is reported that loss of libido, orgasmic dysfunction, decreased clitoral arousal and decreased frequency of sexual intercourse can be seen in the postmenopausal period [9]. Other than neurovegetative changes, vulvovaginal atrophy may also cause decreased vaginal lubrication and fear of painful coital activity and possible post-coital bleeding can cause women stay away from sexual activity. Urinary symptoms also may add to this negative attitude. These physiological changes provoke anxiety and depressive symptoms and therefore, psychosexual problems ensue [11]. Our results also show this important correlation in both vaginal and urinary subscales. To conclude, as duration of post-menopausal state increases urogenital symptoms begin to affect the women’s lives and these symptoms are in close relation with anxious and depressive psychological state. Hence, physicians should deal with these symptoms and do their best to alleviate those complaints in an aim to ameliorate QOL of post-menopausal women.
69
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