Vol.2, No.11, 1320-1326 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Predicting menopausal health in a diverse population
group through a theoretical linear model
——Theoretical model to predict menopausal health
Amit Sengupta1,2*, Nithya Srinivasan3
1Central Health Services, CGHS, Mumbai, India;
2Biomedical engineering, Indian institute of technology, Delhi, India; *Corresponding Author: senguptaamit@hotmail.com;
3Central Government Health Scheme (CGHS), Mumbai, India.
Received 24 August 2010; revised 30 August 2010; accepted 14 September 2010.
With the increase in longevity and demographic
shift, menopause is emerging as one of the ma-
jor health issues affecting middle aged women
in developing countries. In this study our aim
was to define & develop useful predictive indi-
cators to assess menopausal health status in
women with diverse socio-economic & cultural
backgrounds. The model was developed using
the data drawn from known published works as
well as our own epidemiological & clinical case
records. A linear equation was derived and ex-
pected results were obtained and analysed. The
outcome was measured in terms of menopausal
health & wellbeing index. Wide cultural diversity,
unequal socio-economic status and gender ine-
quality are some of the sensitive multi factorial
determinants that influence the menopausal heal-
th. Education and availability of optimal quality
health care facilities positively influenced level
of awareness and improved the health seeking
behavior & health literacy. The menopausal health
& wellbeing index can be used as a predictive
tool to develop interventional management mo-
dalities to improve quality of life.
Keywords: Menopause; Quality of Life; Urban
Indian Women; Socio-Cultural Factors; Health
Literacy; Theoretical Model
Women constitute 70% of world’s poorest and 90% of
the landless people. In India, 60% of women beyond the
age of 50 are widows, and more than 80% elderly
women beyond 60 years of age live in extended families
with grown up children, yet more than 80% suffers af-
fective syndrome [1,2]. With rapid demographic changes,
the number of elderly population is gradually rising and
the ratio of elderly & young adults is expected to reach
1:4; and by 2020, the actual number of women aged
more than 50 will be nearing 150 million in India. The
situation in the developed countries is more alarming
with the ratio reaching 1:2, showing a high dependency
rate. Thus, menopausal health assumes greater significance
especially for those who suffer symptom and substantial
morbidity. Moreover, menopausal health which signifies
overall health and well being status of a woman during
and beyond middle age is also linked to various socio-
economic, cultural, physiological as well as psychologi-
cal factors. Though physiological alteration in the cycli-
cal ovarian function begins early at the commencement
of climacteric period i.e., around 35 years of age but
morbid conditions such as vasomotor instability, psy-
chosexual problems, mental-physical exhaustion, anxi-
ety-palpitation or genitourinary discomfort, bony pains
in general and osteoporosis, diabetes & coronary arterial
disease in particular are commonly seen later during
and/or after menopause. They are generally ignored in
rural, sub-urban as well as urban India, even if they suf-
fer from symptoms silently [1-6]. However, menopause
is gradually emerging as an issue in India where tradi-
tionally it was linked to aging. M. Flint [4] and M. Bour-
let [7] did extensive Socio-anthropological and morbid-
ity studies on menopause in India and South East Asian
countries. Scarce availability of quality health care fa-
cilities, gender inequalities, lack of awareness in rural,
semi-urban and urban areas prevents women from seek-
ing much needed medical support for conditions such as
osteoporosis, recurrent GUI (genitourinary infections),
SUI (urinary stress incontinence), DM (Diabetes melli-
tus), HT (Hypertension), CAD (coronary arterial disease)
and affective disorders etc. The lack of assured basic
A. Sengupta et al. / HEALTH 2 (2010) 1320-1326
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
health care facilities, poverty, malnutrition, illiteracy was
considered some of the reasons for imperceptible im-
provement in their health in poor developing countries
[8,9]. Even in US low income and poor education was
found to be associated with increased menopausal
symptoms and determining age of peri menopause [10,
11]. Income, place of residence (urban/rural) and educa-
tion level of women also modifies health seeking be-
havior and house hold expenditure on health [8,9]. Stud-
ies also suggested a link between early life factors, good
health care support received during the reproductive pe-
riod and better health status of women entering meno-
pause or the phase of reproductive agin [12]. It is also
well known that the women across different cultures and
ethnicity perceive and behave differently during meno-
pause. The cultural attributes affect women’s menopau-
sal experience in a very complex way [1,3,4,7,13-18].
Traditionally India is a multilingual, multi ethnic, multi-
religious nation where population co-exists concurrently
in societies corresponding to ancient, medieval and mo-
dern era, and as a result wide variations in their health
status and human development index is seen. Apparent
positive mental attitude towards aging and/or menopause
is attributed to the cultural upbringing whereas on the
contrary it also points toward their negative health seek-
ing behavior [1]. Great efforts have been made by de-
veloped nations to alleviate sufferings through a multidis-
ciplinary approach where symptoms expressed during
menopause have been quantified in the form of different
menopause rating scales [19-21]. But escalating cost and
recent controversies surrounding hormone therapy ap-
peared to have raised some concerns on the issue of
quality of life of women entering menopause-climacteric.
Thus, a complete review of issues and factors such as
demographic, nutritional, life style linked to menopause
and its management is currently underway in the devel-
oped world [22,23]. In India where it was poorly studied,
acquiring & generating population based specific infor-
mation on menopause is of vital interest to the policy
makers. The task is not only difficult but also quite chal-
lenging because of non-homogeneous diversified nature
of population group and many contradictions, whereby
rating health related quality of life appeared difficult;
some of them is gross inequitable distribution of wealth
and gender gap which affect women’s morbidity pattern
and health seeking behavior differently. Thus, in any
such given situation where it is difficult to define or pre-
dict complex biological or epidemiological event, mod-
eling is a useful alternative tool, which when properly
constructed by simplifying various complex assumptions,
may predict the outcome closer to real clinical studies.
We proposed a theoretical model to assess & predict
inter-relationship between key human development in-
dices, behavior, attitude and morbidity pattern during
menopause and expect the model to be useful in sug-
gesting preventive & interventional modalities that can
be incorporated in the health care delivery management
protocol so as to prevent menopause related morbidities.
Menopause is influenced by socio-economic, gender,
cultural, behavioural, biological, physical and endocrinal
factors therefore an integrated multi-factorial model on
menopausal health in any diverse heterogeneous popula-
tion group will be an appropriate tool. In order to con-
struct a model, relevant data for India were acquired
from the published research papers [1,2,5,6,24,25]. In
addition, the model was also validated with the support
of some interesting data generated from retrospective
analysis of the records of 209 middle aged women be-
longing to an economically privileged group which was
initially not intended for research purpose but basically
compiled for our routine office purpose. Written and
verbal consent to fill up the pre-treatment questioner are
routinely taken from every woman attending our meno-
pause clinic as part of the clinical protocol. Based on
analysis of the data and keeping in view some of the key
causative attributes linked to menopause, a simple linear
model was proposed and validated. Menopausal health
& wellbeing constant was derived.
2.1. Formulation of a Theoretical Model
1) Quantification of menopausal health & wellbeing
of a woman requires formulation of an index or measur-
ing scale. India and Asia have pluralism and heterodoxy
where it is difficult to acquire specific data for quantifi-
cation or standardization of the quality of life index. In
the absence of specific real time data, theoretical model
is an ideal & powerful decision making tool that can
solve various complexities linked to biological or human
phenomenon. However, real complex assumptions need
to be simplified in order to construct a model and apply
it to predict the outcome from an observational study.
The model should be validated using patient/population
specific data from the studies. We studied socio-economic
data, morbidity pattern, relevant investigation and treat-
ment follow up details from both published as well as
unpublished sources as mentioned above. In this study,
broadly five relevant parameters were considered based
on our search findings (multi factorial model). They are
as follows: For socio-economic status, we have consid-
ered UNDP’s Human development index (HDI) [2,24,25]
that included most of the relevant factors enumerated
A. Sengupta et al. / HEALTH 2 (2010) 1320-1326
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below e.g., the socio-economic security, education ac-
cess, life skill development, life expectancy, literacy rate,
the women’s rights issues like gender inequality i.e.,
given by Gender development index (GDI) inequalities .
It is simply the HDI adjusted downwards for gender
inequalities. HDI – GDI = measures gender disparities;
GE (Gender equality) is good if HDI – GDI (penalties
for gender inequalities) is low and poor if HDI – GDI is
high. GDI measures achievements in the same dimen-
sions and variables as the HDI but captures inequalities
and is uniformly low (penalty for gender inequalities) for
most of the developed nations with homogeneous popu-
lation groups [24]. For our model we added the actual
figures for HDI & GDI to observe overall combined
impact both the indices (Development indices - DI) may
have on menopause.
2) Awareness on menopause & all its aspects (Meno-
pausal health literacy-MHL): Percentage of women aware
of menopause has been calculated as median value vary-
ing between 0 (none of the women aware of menopause)
to 1 (All women aware of menopause).
3) Attitude/belief towards menopause (Ac) is linked to
their cultural attributes. It is the percentage of women
who believe menopause to be a positive event in their
life cycle. The calculated median value varies between 0
(none with positive attitude) to 1 (all with positive atti-
4) Morbid symptoms (Mo) related to menopause was
either expressed by women or retrieved by the physi-
cians. Median value varies between 0 (none with symp-
toms) to 1.0 (all with symptoms).
2.2. The Equation
It is given by a simple linear mathematical arithmetic
equation as proportionality constant (δκ) for menopausal
health. This was to observe the multi factorial effects
that may exert its influence in determining menopausal
health of women.
MHI α DI (menopause health index directly propor-
tional to development index)
MHI α MHL (MHI directly proportional to meno-
pause health literacy)
MHI α Ac (MHI directly proportional to attitude/cul-
MHI α 1/Mo (morbidity), i.e., short term and long
term morbidity (a)
Whereas SCE (Socio-Cultural-Educational-Economic
attributes) = (DI+MHL+Ac) (b)
Therefore, from (a) & (b), we derived MHI = δκ (SCE)
/ Mo for a particular time period (t0….tn)
While assuming δκ = 1 (non-zero) menopausal health
proportionality constant for all cohort group.
Based upon our observation, we expect a linear rela-
tionship between reductions in morbidity and SCE, thus
when we plot a graph between Mo Vs SCE, we may get
a descending curve. An ascending curve is derived when
we plot MHI Vs SCE, i.e., with improvement in SCE the
MHI also improves and vice versa, assuming the value
for Mo to fall. While computing data from longitudinal
prospective survey to observe the effect over a period of
time in a community, the constant fall and rise in the
value of δκ (t0, t1….tn) would suggest gradual im-
provement and deterioration respectively over a period
of time in menopausal health. The value δκ will ap-
proach unity (1.0) when the morbidity becomes negligi-
ble theoretically but for all practical purposes it is not
achievable. Given the unit value of 0-1 (median value)
for each variable, the calculated MHI value will swing
between the range of [(0.0) to (α) (most unfavorable to
most favorable)] theoretically, whereas actual values will
be fluctuating in a range bound manner as shown below
2.3. Validation & Data Retrieval
Details such as age, age at menopause, duration of
menopause, gross family income, level of education,
present/past medical history, personal history, cultural
practices, belief, attitude, awareness on menopause/HRT,
perceived relief, source of anxiety regarding HRT, etc,
were included. A number of western studies are available
to study HRQoLI (health related quality of life index)
during menopause. The questionnaire format that is fol-
lowed in our menopause clinic on quality of life indices
and morbidity patterns were developed following exten-
sive search of literature to ensure its validity and reliabil-
ity [2,19-21]. As part of the protocol, routine and spe-
cialized tests such as blood sugar, CBC, lipid profiles,
ECG, pap screening, complete biochemical, endocrinal,
radiological and color Doppler-sonography tests, besides
dual energy bone densitometry and sono-mammography
were done as and when required. Their height, weight,
BMI, blood pressure recorded and other relevant sys-
temic, breast and gynaecological/pelvic examination
including PAP test were also done routinely. The statis-
tical analysis was carried out using SPSS-PC program
(version 11.0 for windows). A descriptive analysis was
performed for population variables as mentioned above
and binominal distribution, chi-square and log regression
tests were used to study qualitative variables.
We observed that the MHI (menopause health index)
calculated from the derived equation can be used for
conducting comparative studies between rural, semi-urban
A. Sengupta et al. / HEALTH 2 (2010) 1320-1326
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
and urban population. In the absence of well established
HRQLI (health related quality of life index) for a non-
homogenous population group belonging to developing
countries such as India. We arrived at some figures for
MHI as shown below for the study purpose. A marked
difference was observed between urban metro economi-
cally privileged population (our group) with MHI of 4.8
and rural/semi-urban population with MHI of 2.6. (Data
from other sources are compared, see the text above).
(Eqs.1,2), assuming the menopausal constant (δκ) as 1.
India (overall) = 0.5 + 0.5 + 0.3 + 0.8 / 0.8 = 2.6 (low
MHI) (1)
India (metro-middle class) = 0.8 +0.8+ 0.7+ 0.6 / 0.6
= 4.8 (Middle MHI) (2)
(HDI & GDI = 0.5 & 0.8 for an average Indian &
metro middle class Indians respectively; assuming an
approximate value for calculation purpose, the median
value for knowledge of menopause amongst rural and
urban population is 0.3 and 0.7 respectively; median
value for positive belief or attitude amongst rural &
urban population is given the value of 0.8 and 0.6 re-
spectively; average/median value of women expressing/
or retrieved or suffered from menopause symptoms in
rural & urban population was 0.6.
For developed countries where GDI & HDI is con-
stant for a homogeneous population groups, the com-
parison was done on the basis of known specific meno-
pause morbidity scales such as Greene [19], MRS [20]
etc., The other two parameters i.e., awareness level and
attitude was also taken into consideration [11,13,14,19-
21,24,25,28]. For example, if we compare the two
groups of population e.g., Singapore (ASEAN) or Tokyo
(Japan) or and Sweden (Europe-west), they have more or
less a similar development index; HDI, GDI & aware-
ness level assumed to be constant but their difference
can be described on the basis of their different cultural
attitude and perception of symptoms as well as actual
short term & long term morbidity.
For developed nations or for a small group of affluent
Indian urban women, it could be = 0.9 +0.9 + 0.9 + 0.7/
0.6 = 5.6 (high MHI) (3)
The discussion focuses on validating the derived
equations taking into consideration data retrieved from
literature as well as our own case records wherever ap-
plicable. The values for the cohort/country etc. are de-
rived from UNDP reports and various other studies as
mentioned in the reference section. For India which is a
developing country with non-homogeneous population,
comparative values for cohort groups e.g., rural, semi-
urban or urban-metro cities have been derived using data
from the present study as well as from the published
work [1,2,5,6,8,9,16,24-27]. The general profile of our
economically privileged & medically insured middle
aged urban (METROPOLITAN) women showed a very
high literacy rate of 93% with 36% university graduates
as compared to the national female literacy rate of 54%
(urban vs. rural :73 vs. 46). 43% of them were employed
in organized sectors as against the national average of
30% who are economically active, mostly doing menial
jobs in unorganized sectors. Amongst economically pri-
vileged urban population, 86% and 65% women with
graduate educational qualification were aware of meno-
pause and HRT respectively. The ODD’S of not knowing
menopause as a clinical entity and HRT as therapeutic
modality was 4.5 (p < 0.005) and 3.4 (p < 0.01) times
greater in women with secondary level education (high
school completion) as compared to the university gradu-
ates. The ODD’S of not being able to express or link hot
flushes with menopause was 2.2 (p < 0.07) times greater
in women who had no knowledge of menopause. The
mean age of menopause in our study group was 45yrs,
surgical (43 +_ 6yrs): natural (48 +_ 4yrs). Women be-
longing to underprivileged group’s experienced early
menopause i.e., mean age vary from 40 to 48 years
[6,26-28]. The mean age of menopause in developed
countries is higher and varies between 48-51 years [17].
Our economically privileged educated urban women
appeared less positive (47.6%) when compared with the
economically deprived rural & semi-urban Indian women
(94%). 88.83 % of all women from our urban metro
group consulted physicians practicing evidence based
medicine. Only 8% women with the knowledge of
menopause do not express any morbid symptoms related
to peri-menopause compared to 20% & 35% who had
vague knowledge or no knowledge about menopause
during peri-menopause period respectively. Menstrual
irregularity (32/83 = 38.5%), psychosomatic problems
(17/83 = 20.5%) and the bony or musculoskeletal pains
(10/83 = 12%) were three most common morbid condi-
tions affecting the quality of life in our economically
privileged urban women during peri-menopause. Geni-
tourinary morbidity was more beyond 65 yrs of age. The
educated urban women reported more vasomotor symp-
toms-VMS (71-86%) as compared to 17.1% in semi ur-
ban India. Better awareness level of educated & eco-
nomically privileged urban women appears to be an in-
fluencing factor in expressing the morbid symptoms
thereby seeking early remedial measures compared to
those who were generally unaware of menopause and
suffers silently. Nearly one-quarter of Japanese commu-
nity-dwelling, healthy women in the peri- and post me-
nopausal states suffered from menopausal symptoms,
which decreased their quality of life in everyday life [29].
The Chinese women displayed a low to moderate fre-
A. Sengupta et al. / HEALTH 2 (2010) 1320-1326
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
quency of reporting symptoms across vasomotor, vaginal,
sleep-related, cognitive, emotional and somatic catego-
ries. Their attitude toward menopause and aging tended
to be more positive, neutral or ambivalent, as opposed to
negative [30]. The affluence of our emerging middle class
had a direct influence on BMI, majority of them were
found to be overweight. Obesity or high BMI (> 25) was
found in 59 % women in our group as compared to the
national average of 11.6%. BMI and morbidity: A link
was found between overweight or obesity (high BMI)
and psychosomatic illness, hypertension, diabetes & al-
cohol intake. The absence of anemia also suggested
good nutritional status amongst our affluent group. In
India 60% of all women between 15 to 60 years of age
are anemic. [2,27]. Alcohol and Smoking: All women
consuming alcohol in our study group were overweight
and on HT/HRT therapy. 70% had surgical menopause.
25% of women smokers in the group were on HT/HRT
and 50% had normal menopause. Natural and Surgical
Menopause: More women suffered hot flushes follow-
ing the hysterectomy compared to those who had natural
menopause [(55/67 (82%) vs. 75/110(68%) p < 0.05)].
We also observed higher hysterectomy rate (14%)
amongst the urban educated women attending our me-
nopause clinic compared to 5.8 % in semi urban India
[5]. 28.9% of women were individualized to receive dif-
ferent types of hormone therapies including Soya – iso-
flavones for various menopause related morbidity at
any given point of time in our group. This was in sharp
contrast to almost none from the semi urban areas re-
ceiving HT/HRT even though they silently suffered
symptoms almost equally [5]. In one of the recent stud-
ies, 58% of African-American women used HRT or con-
sidered using it [31]. The use of most types of CAM
were not related to menopausal status or symptom re-
porting but to socio-demographic factors, co-morbidities,
and health behaviours as reported in another US study
[32]. Based upon the analysis of the data as mentioned
above, we defined certain broad intervention modalities
i.e., firstly, to promote positive attitude, secondly, to im-
prove the developmental indices i.e., HDI & GDI and
thirdly to reduce the severity of menopausal symptoms
Attitude can be improved through positive thinking, and
integrating complimentary therapies like yoga and coun-
seling and also multi-cultural integration of various cul-
turally secluded groups towards a common goal of heal-
thy living; it was observed that as long as the Indian
women remained within their cultural sphere, they did
not show much appreciable behavioral changes and suf-
fered from mental or bodily symptoms silently without
being aware of the need for intervention. Mental health
can also be improved through promotion and preserva-
tion of extended family support systems. We also must
promote life style change through exercises, regulating
the diet in order to maintain the ideal body weight and
reduce menopause related diseases. Women should be
educated & economically empowered which in turn will
help in generating awareness on menopause & its short -
long term health related changes. Attention should also
be focused on the availability of various therapeutic
modalities. Efficient evidence based health care facilities
should be strengthened and extensive studies be initiated
to assess the menopause related morbidity across various
cross sections of population. Medical audit is necessary
to reduce surgical (total hysterectomy) interventions for
DUB. Overall objective behind doing this is to improve
quality of life. We felt while general family physicians
may assume the key role in conducting primary health
screening, high risk severe cases may be referred to a
specialist for better management of specific conditions
such as severe psycho-motor symptoms, osteoporosis,
stress urinary incontinence etc. after assessing them us-
ing known scoring system e.g., MRS, Greene etc.
EDUCATION-improves body-mind interaction (Know-
ECONOMY-improves Nutrition & self confidence but
overweight becomes a problem,
AVAILABILITY of service-improves Health seeking
behavior & expression
AUDIT-Promotes evidence based medicine (EBM)
vis-à-vis cultural practices, which will be helpful in ana-
lyzing use of various modalities of treatment, evidence
based or traditional. Unless corrective measures are
taken now, global economy will be seriously affected
due to ever growing number of elderly women suffering
from symptoms and morbidity.
An integrated MHI is useful for comparative analysis
as well to observe the gradual improvement in meno-
pausal health status of middle aged women in a devel-
oping country. Based on the equation and the derived
values, we conclude that higher level of education &
income, greater awareness positively influenced the qua-
lity of health of middle aged women during menopause.
Health seeking behavior of women, attitude of health
care providers and availability of quality health care fa-
cilities may affect treatment and management modalities
during menopause. In general, there is a greater need to
make women and society in a developing country health
literate i.e., providing them with the right kind of infor-
mation about menopause, suggesting alternatives to hys-
terectomy and importance of individualized hormone
replacement therapies or modulators or Soya (isoflavones)
A. Sengupta et al. / HEALTH 2 (2010) 1320-1326
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
Openly accessible at
to alleviate severe acute symptoms and long term prob-
lems like osteoporosis, Alzheimer’s etc. Greater emphasis
should be laid on regular health check up of middle aged
women in order to identify the impending risks of hy-
pertension, diabetes mellitus, coronary arterial diseases
ASG is the consultant in obstetrics and gynecology as
well as a professor of biomedical engineering in a pre-
mier teaching and research institute, working towards
betterment of women through use of innovative biome-
dical technology and analysis. NS is a research worker
currently working in the field of cancer cell biology.
The authors show their sincere gratitude to Professor Prakasam,
Professor of Biostatistics, International Institute of Population studies,
Mumbai for making facilities available at the data centre and for his
technical help & constructive inputs in analyzing the data. The authors
would also like to thank sincerely Dr. Prasad Bonerjee, Research
scholar at IIPS, Mumbai, for formatting the pre-tested structured me-
nopause questioner forms into a SPSS compatible data sheet, and for
training us in using SPSS system while solving problems in data han-
dling. We specially acknowledge the helpful discussions we had with
Dr. Sainani, Additional Director of CGHS Mumbai on epidemiology &
women issues. We would also like to thank Ms. Sonia Dharware, staff
nurse, who meticulously maintained and preserved all the case records.
Conflict of interest-None
Source of funding-None
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