Predicting menopausal health in a diverse population group through a theoretical linear model——Theoretical model to predict menopausal health

doi:10.4236/health.2010.211197

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Vol.2, No.11, 1320-1326 (2010)

doi:10.4236/health.2010.211197

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.

ABSTRACT

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

1. INTRODUCTION

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

1321

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.

2. METHODS AND MATERIALS

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-

tude).

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-

ture/belief)

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

(Eqs.1-3).

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.

3. RESULTS

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

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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)

4. DISCUSSIONS

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

1324

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.

Summarizing:

EDUCATION-improves body-mind interaction (Know-

ledge/awareness/Attitude/Belief)

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.

5. CONCLUSION

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

1325

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

etc.

6. AUTHOR’S INFORMATION

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.

7. ACKNOWLEDGEMENTS

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

REFERENCES

[1] Sengupta, A. (2003) The emergence of the menopause in

India. Climacteric, 6, 92-95.

[2] WHO (2000) Women of South East Asia, a health profile.

New Delhi: Regional publications SEARO, 34.

[3] Bush, T.L. (1990) The epidemiology of cardiovascular

disease in post menopausal women. Annals of the New

York Academy of Sciences, 592, 263-271.

[4] Flint, M. and Samil, R.S. (1990) Cultural and sub-cul-

tural meaning of the menopause. Annals of the New York

Academy of Sciences, 592, 134-148.

[5] Kaur, S., Walia, I. and Singh, A. (2004) How menopause

affects the lives of women in suburban Chandigarh, India.

Climacteric, 7(2), 175-180.

[6] Singh, A. and Arora, A.K. (2005) Profile of menopausal

women in rural north India. Climacteric, 8(2), 177-184.

[7] Boulet, M.J., Oddens, B.J., Lehert, P., Vermer, H.M. and

Visser, A. (1994) Climacteric and menopause in seven

SE Asian countries. Maturitas, 19, 157-176.

[8] The World Bank (1996) Improving women’s health in

India. Development in Practice Series, New York, Oxford

University press for the WB.

[9] Rout, H.S. (2006) Linkages between income education

and health: Case of rural Orissa. The Indian Economic

Journal, Indian Economic Conference Volume, 70-79.

[10] Wise, L.A., Krieger, N., Zierler, S. and Harlow, B.L.

(2002) Lifetime socioeconomic position in relation to

onset of per menopause. Journal of Epidemiology and

Community Health, 56, 851-860.

[11] Brzyski, R.G., Medrano, M.A., Hyatt-Santos, J.M. and

Ross, J.S. (2001) Quality of life in low-income meno-

pausal women attending primary care clinics. Fertility and

Sterility, 76(1), 44-50.

[12] Mishra, G

.D., Cooper, R., Tom, S.E. and Diana, Kuh.

(2009) Early life circumstances and their impact on me-

narche and menopause. Women’s Health, 5(2), 175-190.

[13] Parsons, M.A. and Obermeyer, C.M. (2007) Women’s

midlife health across ultures: DAMES comparative ana-

lysis. Menopause , 14(4), 760-768.

[14] Robin, G. and Nanette, S. (2009) Menopausal symptoms

and ethnicity: The Study of women’s Health Across the

Nation. Women’s Health, 5(2), 127-133.

[15] Christopher, E. and Jacqueline, S. (2003) Reproductive

and sexual health of older women in developing coun-

tries. British Medical Journal, 327, 64-65.

[16] Gupta, P., Sturdee, D.W. and Hunter, M.S. (2006) Mid-

age health in women from the Indian subcontinent (MA-

HWIS): General health and the experience of menopause

in women. Climacteric, 9(1), 13-22.

[17] Sommer, B., Avis, N., Meyer, P., Ory, M., Madden, T.,

Kagawa-Singer, M., Mouton, C., Rasor, N.O. and Adler,

S. (1999) Attitudes toward menopause and aging across

ethnic/racial groups. Psychosomatic Medicine, 61(6), 868-

875.

[18] Loutfy, I., Abdel Aziz, F., Dabbous, N.I. and Hassan,

M.H. (2006) Women’s perception and experience of me-

nopause: A community-based study in Alexandria, Egypt.

Eastern Mediterranean Health Journal, 12(Suppl 2), S93-

106.

[19] Greene, J.G. (1998) Constructing a standard climacteric

scale. Maturitas, 29(1), 25-31.

[20] Schneider, H.P.G., Heinemann, L.A.G. and Thiele, K.

(2002) Menopause rating scale (MRS): Linguistic and

cultural translation into English. Life and Medical Science

Online, 3, 1-13.

[21] Zollner, Y.F., Acquadro, C. and Schaefer, M. (2005) Lit-

erature review of instruments to assess health-related

quality of life during and after menopause. Quality of Li-

fe Research, 14(2), 309-327.

[22] Gold, E.B., Block, G., Crawford, S., Lachance, L., Fitz-

Gerald, G., Miracle, H. and Sherman, S. (2004) Lifestyle

and Demographic Factors in Relation to Vasomotor Sym-

ptoms: Baseline Results from the Study of Women’s Health

Across the Nation. American Journal of Epidemiology,

159, 1189-1199.

[23] Melby, M.K., Lock, M. and Kaufert, P. (2005) Culture

and symptom reporting at menopause. Human Reproduc-

tion Update, 11(5), 495-512.

[24] Bardhan, K. and Klasen, S. (1999) UNDP Gender Re-

lated indices: A critical review. World Development Re-

port, 27, 985-1010.

[25] United Nations Development Programme (1999) Human

development report. Oxford University Press, New York.

[26] Syamala, T.S. and Sivakami, M. (2005) Menopause, an

A. Sengupta et al. / HEALTH 2 (2010) 1320-1326

1326

emerging issue in India. Economic and Political Weekly,

40, 4923-4930.

[27] National Family Health Survey (NFHS-2), 1998-99, under

Reproductive and child health project. International In-

stitute for Population Studies (2001, phase I&II), Mum-

bai, India.

[28] Gold, E.B., Bromberger, J., Crawford, S., Samuels, S.,

Greendale, G.A., Harlow, S.D. and Skurnick, J. (2001)

Factors associated with age at natural menopause in a

multiethnic sample of midlife women. American Journal

of Epidemiology, 153(9), 865-874.

[29] Satoh, T. and Ohashi, K. (2005) Quality-of-life assess-

ment in community-dwelling, middle-aged, healthy wo-

men in Japan. Climacteric, 8(2), 146-153.

[30] Shea, J.L. (2006) Chinese women’s symptoms: Relation

to menopause, age and related attitudes. Climacteric, 9

(1), 30-39.

[31] Sharps, P.W., Phillips, J., Oguntimalide, L., Saling, J. and

Yun, S. (2003) Knowledge, attitudes, perceptions and pra-

ctices of African-American women toward menopausal

health. Journal of National Black Nurses’ Association,

14(2), 9-15.

[32] Gold, E.B., Stemfield, B., Kelsey, J.L., et al. (2000) Re-

lation of demographic & life style factors to symptoms in

a multiracial/ethnic population of women 40-55 years of

age. American Journal of Epidemiology, 152, 463-473.

[33] Cristina, K., Haider, M.A., Junior, J.M.S., Nunes, M.G.,

Quadros, L.G.A., Kemp, C., et al. (2006) Randomized

clinical trial comparing CEE and isoflavones in post me-

nopausal women-apilot study. Maturitas, 53, 49-58.

[34] Kronenberg, F. (1990) Hot flushes: Epidemiology & phy-

siology. Annals of the New York Academy of Sciences,

592, 52-86.

[35] Thompson, B., Hart, S.A. and Dumo, D. (1973) Meno-

pause age and symptomatology in a general practice.

Journal of Biosocial Science, 5, 71-82.