Women’s Experiences on Menopause: A Phenomenological Study

Menopause is the permanent termination of menstruation resulting specific symptoms such as hot flashes, mood swings, sleep disturbances, forgetfulness, vaginal dryness and weight gain. Women suffer from these symptoms because such symptoms affect their day-to-day life and finally lead to decrease in the quality of life. Therefore, it is pivotally important to study the experience of women during menopause. The aim of this study is to explore women’s experiences of menopause. Purposively selected 20 women who experienced menopause were recruited for this qualitative phenomenological study at the Gynecological Section of the District General Hospital, Matale. Data was collected by semi-structured interviews conducted during a period of one month and data analysis was done using Colalizzi’s analysis method. Four (04) themes emerged from the findings, which are: unbearable discomfort in the body, emotional instability and memory problems, problematic issues in family relationships, and increased expenditure for the treatments. Hot flashes, sleep disturbances, joint pain, vaginal dryness and weight gain were the physical experiences. Further, there were psychological experiences of menopause such as difficulties in making decisions, forgetfulness, fits of anger, mood swings and frustration. Moreover, women’s menopausal experiences also affected their family life and economy. Women noted that * Correspondence should be addressed to B.S.S. De Silva. Email: bssil@ou.ac.lk https://orcid.org/0000-0002-8824-9833 (Received 15th August 2017; Revised 28th October 2017; Accepted 10th November 2017) © OUSL 43 DOI: http://doi.org/10.4038/ouslj.v12i2.7407 D.G.C.N. Samarasiri, I.T.Rajanayake, P.K. Wattegedara, R.D. Kodituwakku, A.S.P.L. Senadheera and B.S.S. De Silva decreased libido and lack of motivation were affecting their family life, while experiences of poor time management and additional expenditure on medical treatment were adding to the existing burdens of family economy. The findings revealed that women suffer from different experiences during menopause and they suffer because, those changes reduce the quality of their lives. Such personal changes, though they are manageable, could lead to issues such as rupture in personal roles within the family and immediate society. Hence, these study findings can be used to provide them with better health care and knowledge.


Introduction
The word 'menopause' is derived from the Greek words 'men' and 'pause' and it is referred to as a series of the psychological and physical changes in women's life after termination of menstruation (Hoda et al., 1993).Usually, it is identified by the absence of menstruation for duration of 12 months (Soules, 2005).This is often regarded as a significant event in a woman's life and it is accompanied by a series of biological and psychosocial changes (Bernis & Reher, 2007) and they have to adapt to a new biological state (McKinney et al., 2012;Speroff & Fritz, 2005).The mean age of menopause is around 51years and it ranges from 45-55 years in many countries (Ramakuela, 2015;Gharaibeh, Al-Obeisat & Hattab, 2010).In Sri Lanka women's life expectancy has extended upto 79 years (Ministry of Health, 2012) and the mean age of menopause is around 51 years.Therefore, women in Sri Lanka will spend around 1/3 of their life after their menopause.So, it is important to pay more attention to the quality of their lives (Inceboz et al., 2010).
Women usually experience menopause after facing many coincidental changes in their lives.These include, children getting married and leaving home, parents becoming ill or dying and personal health problems.These events force women to cultivate coping skills and behave in a mature and respectable manner.Menopause is a crucial turning point of a woman's life and it is naturally designed as an aspect of the aging process (Ramakuela, 2015).So, this is the entry point for old age and it reduces the quality of life of women, and so women are not ready to accept these manageable changes at once (Ramakuela et al., 2014;Kilaf & Kirchengast 2010).However, menopause is considered a taboo subject and people are discouraged from discussing it (Formanek, 1990).
Menopause results from the reduction of secretion of ovarian hormone levels, including estrogen and progesterone due to the changes in the urogenital epithelium (Ramakuela, 2015).It also causes the decrease of other hormones as well (Jones & Boelaert, 2015).This leads to the arising of various biological and psychological changes in women (Speroff & Fritz, 2005;McKinney et al., 2012) and they could suffer from these symptoms in various degrees that could eventually disrupt their lives (Hoda et al., 1993).With the reduction of sex hormones, a woman experiences physical changes including hot flashes, vaginal dryness, vaginal atrophy and insomnia.It also results in cognitive changes and changes in memory (Bernis &, Reher, 2007;Greenblum et al., 2013).A hot flush is a symptom which suddenly results in a feeling of warmth that spreads throughout the body, especially over the face, neck, and the chest.This often arises with profuse sweating followed by a chill and could last for 2-3 minutes.Around 65% of women suffer from hot flush (Gold, Sternfeld & Kelsey, 2000) while about 47% have reported vaginal dryness, itching, discomfort, and dyspareunia during the later postmenopausal period (Dennerstein, et al., 2000).The above-mentioned changes have a negative impact on a woman's sexual life, family relationships and socio-economical life (Genazzani, 2000).Around 85% of females suffer from these symptoms (Goodman et al., 2011).With the reduction of these hormones, there is a tendency for unhealthy conditions like osteoporosis, obesity, diabetes mellitus and heart diseases to occur.
Today, women increasingly contribute to the labor force and play roles in higher key positions in the commercial sector.So, they engage in activities like driving, which increase the risk of injury.Women who are un-employed raise children and engage in other household activities.Therefore, it is essential to pay attention to the quality of their lives.Understanding women's experiences are important to improve their quality of lives through providing better care.

Methodology
A qualitative phenomenological design was utilized in this study to explore women's experiences of menopause.The experiences are qualitative and difficult to quantify.Also, this is the best type of study design which could be used to explore women's 'lived experiences' adequately and in-depth because people are allowed to talk freely (Hancock, Ockleford, & Windridge, 1998;Marriam, 2009).

Study Settings and Participants
The participants of this study were women who sought medical treatment for their menopausal symptoms at the Gynecological Section in the District General Hospital, Matale.Twenty women, who were purposively selected, were recruited for the study.They were in the age category 45-60 years and have experienced menopause for a period less than one year.Their willingness to discuss experiences of menopause was also considered when selecting the sample.Women who had bleeding disorders and a surgical history were excluded from the study.

Ethical Consideration
Ethical approval was obtained from the Ethics Review Committee of the General Hospital, Kandy and the permission for this study was taken from the Director of the District General Hospital, Matale.All the participants were fully informed about the purpose of the study prior to conducting the study.Informed consent was obtained from each and every participant before collecting the data and voluntary participation was encouraged.Anonymity and confidentiality were assured by securing the information only among the research team and labeling them with a specific code for collected data.

Data Collection
Semi-structured interviews were used for data collection.A theme list was used to guide the interviews validated by referring appropriate literature and expert opinions (Polit & Beck, 2013).It was translated into their mother tongue and it facilitated the covering of all the required parts in the interviews.Supplementary words such as "How, What, why…" were added accordingly to encourage women to explain their experiences in detail (Burns & Grove, 2016).Consistency and accuracy were maintained by conducting all the interviews by the first author.
During the interviews, the women were separated from friends and family members to facilitate the free expression of their experiences without bias.The interviews were conducted in a calm and quiet place, chose flexible times for the participants and treated them in a respectable manner to minimize stress or physical tiredness.Listening well, encouraging them by demonstrating positive affirmation of their viewpoints, looking at them in an interested manner and other tried and tested interview skills were used to conduct more effective interviews (Merriam, 2009).High quality tape recorders were used to collect data effectively.The investigators were more concerned about the body language, non-verbal clues such as crying, sighing which were used by the women to express their experiences during the interview process (Polit & Beck, 2013).Data was collected for a period of 1 month and every interview was conducted for duration of 40 to 50 minutes on average.

Data Analysis
The data analysis was done using the Colaizzi's method (Shosha, 2010).First, all the recordings were listened to carefully in order to get a clear sense of the whole content of participants' explanations and views.They were transcribed into texts with several reviews.Then, important statements which were relevant to the phenomenon were extracted from them and recorded on separate sheets.The meaning of each phrase was described and defined.The formulated meanings were categorized in to sub themes and then themes and these categories were referred to initial protocols for confirming their validity.The fundamental structure of the phenomenon was described.The descriptions were reviewed to obtain clear meaning and to avoid any ambiguity.Member checks were used to maintain the trustworthiness of the study.

Figure 1. Women's experiences of Menopause
Four (04) themes were derived from the findings, they are: unbearable discomfort in the body, emotional instability and memory problems, problematic issues in family relationships, and increased expenditure for the treatments.These are presented as a model which illustrates the women's experiences of menopause.(Figure 1) Unbearable discomfort of the body Women often suffered from hot flashes during menopause.They have experienced it as a sensation like a hot wave which begins from their feet and spread throughout the body up to the head.It lasts only a few minutes and rapidly disappears 2 to 3 minutes after it had begun.During this period, they felt burning sensations upon the whole of the body.They became reddened, especially on the face and upper body.However, this sign of menopause varied widely among them.Ms. H described her experiences on hot flashes as: "It feels like my ears are going to blow off my head, just fire, it lasts few minutes and then become relaxed.All of a sudden it starts at my feet and my toes feel as if they are burning, and then it goes up my legs and it goes like a wave throughout the body" (Interview 08, Ms. H) These women have experienced sleep disturbances as well.They woke up many times during the night.Insomnia is a sleeping disorder connected with menopause.Both hot flashes and night sweating have created sleep disturbances that were difficult to tolerate, and which increased irritability and stress in women's working lives.They also said that their sleep was less restful and falling asleep became increasingly difficult.One such experience was captured in a statement recorded from Ms. J.

"Most nights I feel very hot. At that time, I have a bath, but it did not help me. I drink water, but not much effective.
Mmm……then I go to sleep.One night, I felt as the whole the room was rotating around me.Then I woke up and opened the window.I felt as if it was the last moment of my life" (Interview 10, Ms. J) Joint pain is one of the most common symptoms women experienced during menopause.It was an indescribable pain, stiffness, or swelling in or around a joint and muscles.Although usually the joint pain often occurs in joints of high impact, such as the knees, hips, and the back, many women experienced such pain in the joints of their hands which had become stiffer and more painful.It badly affected their day-to-day lives.Ms. M explained about her joint pain as follows:

"Work on time Uh…… inability to do my day-to-day work because of severe joint pain, I worry about it (sad mood). Mmm……I cannot manage my work'' (Interview 13, Ms. M).
Weight gain is also another significant problem that results from menopause.Women became more fatty and obese, and therefore often worried about the changes of their body image.Especially, the abdomen became fatty than hips and thighs.According to women, obesity was caused mainly by lack of physical activities and irregular eating habits caused by with severe hunger.Ms.A explained about her eating patterns during menopause as follows: "I feel very hungry; I want to eat seven to eight times a day.I eat a lot and my body becomes fatty and out of shape, I don't know what to do… I worry about my body shape, but, when I feel hungry I do not remember anything" (Interview 01, Ms. A) Suffering from vaginal dryness and changes in desire to have sex were the most crucial and unpleasant experiences for women.Lack of lubrication has led to sex becoming uncomfortable, and the vagina was frequently itchy; there were irritations in and around the vagina, and was more prone to infections.Vaginal dryness was one of the most emotionally distressing menopausal symptoms as it reduces the frequency of engaging in sexual activities.It is important to seek treatment for this condition if it begins to affect the quality of life.As this sudden drop in desire for sexual activity or intimacy were more troublesome and caused dents in the relationship with her life partner.Loss of libido can also be caused by other menopausal symptoms such as vaginal dryness or depression.Ms. L explained her experience of vaginal dryness: "Mmm…..earlier…..we had sex two or three times a week.But, now I feel difficulties.I don't have any feelings.When we are having sex, I felt very painful in my vaginal area.Hh…..Um….. Now we have sex only once or twice a month.
My husband worries about it, sometimes he has got angry with me too" (Interview 12, Ms. L).
The findings revealed that menopause is a stage of life, experienced in different ways.Hot flashes, sleep disturbances and vaginal dryness were the strongest symptoms reported by women.The positive or negative ways in which each woman approaches the changes during menopause are influenced by their personal, family and socio-cultural background.

Emotional instability and memory problems
As a result of menopause, many women have noticed that they have troubles in memorizing, and they experience mental blocks, or face difficulties in concentrating.This can cause confusion, make them worry and can have a significant impact on all aspects of daily life.Therefore, they have to face difficulties in making decisions in their daily activities and working life.Women had revealed that they had changes in their cognitive functions as well.However, inadequate sleep or sleep disruptions can also contribute to the difficulties in decision making and concentrating.Ms. Q described it as follows: Almost all participants described some level of forgetfulness associated with menopause.Women explained about the impact of forgetfulness on their jobs and day-to-day activities.Several women revealed about the need for keeping a list to remind them about their daily responsibilities.Women explained about changes in their moods identified by themselves and family members.
"Sometimes, I go to the refrigerator to get something, but, once I go there, I forget the reason why I went there (laughs) that is my memory loss related to menopause" (Interview 18, Ms. R).
"My husband says, 'you are always moody, what is the matter with you, you are grumpy all the time and snapping at children'" (Interview 14, Ms. N).
Mood swing and anger are surprisingly common among menopausal women, but can be hard to cope with.A woman experiencing mood swings felt like as if she were on a rollercoaster of emotions: one minute she was up, the next minute down.Mood swings were sudden and intense, although the experience of them may differ from woman to woman.Other menopausal symptoms also have a negative influence on mood, such as fatigue.Ms. B explained about her mood swing and anger: "I feel I'm emotionally unstable… so unstable.I'm more sensitive; quite suddenly I start to think about my parents and they are getting old and then I'll be the eldest soon.I think about a lot of things.I think… well, it's hard to take in.These feelings make me sad.At the same time, I think then I will see my grandchildren… Those thoughts make me happy" (Interview 02, Ms. B) Some women said that sometimes they felt frustrated with their lives due to forgetfulness, mood swings and decreased cognitive functions.Thus, these women were under the impression that they were neglected by their close family, friends and others.Feeling of irritability made them upset and caused them to feel fed up about their lives.Such conditions adversely affected their job performances and relationships with family, friends, and coworkers and forced them to seek medical advice.While experiencing those feelings the women also attended religious activities.

"It is something very emotional, when my mind commands me to fight with somebody. There is no reason to fight. I want to give-up everything …I felt that everybody neglected me, I go to the temple every day and stay a long time there" (Interview 06, Ms. F)
Under the theme of emotional suffering, women have experienced forgetfulness, decision making difficulties and mood swings which directly affected their quality of life.

Problematic Issues in family relationships
Women mentioned that they faced family conflicts, especially problems associated with their partners.Emotional instability or irritability appeared as the main reasons for these conflicts.They stated that they were very sensitive and irritable without any apparent reason and this irritability was placing the relationships with their families under stress.Women revealed that vaginal dryness, sweating and abnormal body odors, decreased libido and caused the complete loss of sexual activities in their relationships-these were the main causes for the disruption of relationships.However, several women said that their partners were sensitive to these changes and were supportive of them even when there were changes in their sexual relationships.Other women highlighted that they felt stressful, lazy and they were affected by the lack of family support all of which contributed to decreased motivation in their work.Ms. J described that her husband was very supportive and did not pressure her to have sex: "My husband actually has been very supportive, he….Um……um…. he takes effort to make sure that I know; he does not pressure me to sex or anything else" (Interview 10 Ms. J) Ms. K explained that she lost the connection with her husband.They usually begin in the period of menopausal transition, that is, the time leading up to the final menstrual period, and typically persist throughout post-menopausal period.They include hot flashes, sexual, psychological and mood changes, poor quality sleep and rapidly ageing skin.Due to these changes motivation is decreased among menopausal women in their daily work.Ms. D and Ms. F explained the reasons for their de-motivation due to menopausal experiences: "I can't do many things easily that I usually do.I think that at the beginning the bones were weakening.Once my bones are not strong any more, my mobility becomes limited.I am not motivated to do any work at home or work place" (Interview 4, Ms. D) "These hot flashes, makes me nervous and troublesome.It can be easily seen by other people.Suddenly I become all red.I don't like this at all.Sometimes, when I am just about to go out, all dressed up, suddenly I sweat profusely, and I look like a drowned rat.Then I have to change all my clothes.I like to do work in my workplace but during this period everything messes up and makes me commit mistakes and I feel like given it up" (Interview 6,Ms. F) Under this theme, the findings revealed that menopausal changes have created family conflicts and problematic issues in family relationships.
Increased expenditure for treatment Several women were worried because they were unable to manage their work on time.They revealed that laziness, forgetfulness, anger and joint pain as the reasons for poor time management.It was evident by this explanation: "I was unable to do work on time at home and office, because I felt many difficulties.Joint pain, forgetfulness, lethargy are some of these.Sometimes, I take leave to go home and get sleep" (Interview 11,Ms. K) Women explained that they had to take some treatment for their condition.They have got both western and ayurvedic treatments.They had under gone many investigations from private sector and have spent much money.They had to use various types of cosmetics because the skin became dry.Therefore, they spend much money than earlier.Ms.A described about her additional expenses during menopause period as follows: "At the beginning of these changes I felt lot of discomforts.But then I did not know these changes resulted from menopause.After 4-5 months I understood the situation, but I could not tolerate.I went to get treatment with my husband.I have a breast pain too.The doctor ordered me to do mammogram also.I have spent much money.…Not only that my skin gradually becomes dry.I bought various types of cosmetics to apply all over the body" (Interview 01 Ms. A) According to this theme the women have to spend more money to seek medical treatment.

Discussion
The findings of this study identified that the women underwent different types of experience of menopause during their menopausal transition.In the process of analysis, four major themes were derived from the findings: unbearable discomfort in the body, emotional instability and memory problems, problematic issues in family relationships, and increased expenditure for the treatment.

Unbearable discomfort in the body
Almost all the participants of the study population had various physical experiences of menopause, such as hot flashes, sleep disturbances, joint pain, vaginal dryness and weight gain.Most of women have experienced hot flashes during menopause.Similar results were reported by Waidyasekera et al., (2009).They reported that hot flashes, joint and muscle discomfort, and physical and mental exhaustion were the most prevalent menopausal symptoms.
The other most common physical experience was sleep disturbance.Almost every participant in this study population had experienced sleep disturbance in the form of night sweats.The prevalence of this condition can be compared with other studies in Sri Lanka and developing countries.Similar results have been found in a field-based study from Sri Lanka by Waidyasekara et al., (2009) which showed that 66% of Sri Lanka women have experienced night sweating during menopause.Consequently, Ramakuela (2015) reported that African women have experienced sleep disturbance around the time of menopause more than other experiences.
In addition to those changes, weight gain and joint pain were also the common changes experienced by the study participants.Singh et al. (2012) identified that weight gain and the high prevalence of obesity are common among menopausal women.Although all participants had thoughts on weight gain during menopause and they worried about their weight gain and out of shape bodies.This finding corroborates with Singh et al. (2012) who found that women are not only gaining weight, but also experiencing changes in body composition and fat distribution.
The findings pointed out that vaginal dryness and sexual libido changes were physical experiences of menopause.The impact of decreased libido and intimacy with their partner was a distressing physical changing of menopause.Furthermore, these findings were also noted by Rahman et al. (2010) who emphasized that women frequently experienced sexual problems, and vaginal dryness.Women in the menopausal age (50-65 years) also reported vaginal dryness when compared with younger women (18-34 years) in the UK, Australia, Canada, Italy, Spain, and Argentina which resulted in the decrease of sexual libido (Leiblum et al., 2009).But, in Asian cultures, sexual dysfunction during menopause is often a neglected area.However, now women are more concerned about their sexual wellbeing in latter part of the life (Genazzani, Gambacciani & Simoncini, 2000).

Emotional instability and memory problems
According to the findings, difficulties in making decisions, forgetfulness, anger, mood swing and frustration were the specific emotional cognitive changes of menopause.In this study, women had experiences of difficulty in making decisions in their day-today activities and working life.However, some participants revealed that it was not a problem for their daily activities.This finding is comparable with Bauld & Brown (2009) who showed that difficulty in concentrating and loss of confidence often affect working life.
Moreover, based on the research findings, forgetfulness was another psychological experience of menopause.Women perceived that forgetfulness as a menopausal experience had affected their employment and day-to-day activities.Hoda, Sahorb & Luma (2014) have found 48.3% of women who experienced poor memory in their menopausal stage in a sample of 90 women.
Along with forgetfulness and difficulty in making decisions, participants revealed that anger, mood swings and frustration as the other most common psychological experiences they faced in their menopausal transition.According to the findings in this study, the women easily became angry with their family members.They talked freely with the researchers about the frustration they felt about their lives.Bauld & Brown (2009) found that psychological changes which resulted from menopause could lead to frustration, anxiety, irritability, mood swings and depression which often have an impact on personal relationships and the quality of life.
Increased expenditure for treatment Evidently, the participating women in this study also revealed the socio-economic aspect of their experiences related to menopausal transition.Further, those experiences affected their family and social bonds as well as work and economy.According to the study findings, the experiences of decreased motivation affected their family lives and social bonds.The women revealed that they experienced decrease in their sexual libido and it greatly affected husband--wife relationships.Participants mentioned that due to this experience their husbands quarreled with them frequently.According to Leiblumet et al., (2009), most of participants have reported sexual disinterest after menopause.
Furthermore, women in this study pointed out that decrease in motivation for work as a menopausal experience and that it had greatly affected their family lives and social bonds.Participants mentioned that it disrupted their daily activities at home as well as their future plans.This finding is comparable with that of Inceboz et al. (2000) who showed that 63% of women complained of decrease in motivation in their daily activities after menopause.The findings of this study reconfirmed those views.
However, menopausal experiences of women have also affected their work and economy.The participants of this study mentioned that after their menopausal transition, they could not manage time efficiently and effectively.It directly affected their jobs and economy.Along with these experiences, participants had sought medical treatment.Evidently, they had to add this as additional expenses to their economy.Although they moved on to the medical treatment, they did not receive proper treatment for those difficulties.

Coping technique used during menopause
The women in this study used certain coping techniques to overcome their menopausal experiences.According to Waidyasekera, et al., (2009), the most common techniques were engaging in religious activities, seeking ayurvedic medicines, hormone therapy and exchanging of ideas with their friends/colleagues about menopause.Some women refused to try anything; feeling menopausal was a natural experience that was a part of normal aging.Along with coping techniques, the study participants also revealed that they had to increase their knowledge and attitudes about menopause to overcome the difficult experiences of menopause.

Empowering of women suffering from menopause
The findings pointed out that the knowledge and attitudes about women suffering from menopause should be increased to overcome the difficult experiences of menopause.These women also suffered from several chronic diseases, such as hypertension, arthritis, heart disease and diabetes, which are inevitable conditions associated with middle-age.Therefore, women must be empowered to take decisions concerning their health.These women revealed that health education programs would be a great solution for this.

Conclusions
Menopause had brought a series of challenging experiences to women's lives.Four themes related to menopause were derived from this study, they are: unbearable discomfort in the body, emotional instability and memory problems, problematic issues in family relationships, and increased expenditure for treatment.Located under these themes are women's experiences such as hot flashes, sleep disturbances, vaginal dryness, weight gain, and night sweating.Further, they experienced forgetfulness, memory loss, and difficulties in decision making, anger, mood swings and frustration.Furthermore, women experienced family conflicts and subsequent issues in family bonds.Moreover, they spent money to seek medications for these menopause-related changes.However, it seems that women's knowledge on the subject is inadequate and therefore they tend to suffer.Menopause badly affected the quality of lives and even self-esteem.Many studies revealed that women's coping ability with stress due to changes resulting from menopause can be improved by enhancing their knowledge and attitudes.So, it is recommended to organize awareness programmes for women in the menopausal age to increase their knowledge about menopause.Television, newspapers and social media should be used effectively for this matter.We recommend the introduction of practical coping techniques and strategies to reduce the severity level of menopausal symptoms so that quality of life could be enhanced.It is also imperative to increase the knowledge among nurses about women's experiences on menopause to enhance the nursing care for such women.

"
Mmm……...I always face difficulties in managing my work properly.I cannot control even my class students, sometimes I have to face problem too.When I was teaching students, sometimes I could not continue the class" (Interview 17, Ms. Q) "I have lost connections with my husband; I am irritated all the time......my irritability affected to my relationships-including those with my children.I suddenly get angry and shout at them.Then I asked to myself why did I behave like that?Yes, I lost my sexual interest and I don't care anymore.Just my husband's disappointment makes me stressed and I force myself.... "(Interview 11 Ms. K)