alvina 34 ABSTRACT *Department of Obstetrics and Gynaecology, Medical Faculty, Trisakti University Correspondence dr. Raditya Wratsangka, SpOG Department of Obstetrics and Gynaecology Medical Faculty, Trisakti University Jl. Kyai Tapa No.260 Grogol - Jakarta 11440 Phone: 021-5672731 ext.2706 Email: raditya@trisakti.ac.id; radityaw@indo.net.id Univ Med 2010;29:34-45 Psychosocial aspect determines quality of life in postmenopausal women Raditya Wratsangka* January-Aprl, 2010January-Aprl, 2010January-Aprl, 2010January-Aprl, 2010January-Aprl, 2010 Vol.29 - No.1 Vol.29 - No.1 Vol.29 - No.1 Vol.29 - No.1 Vol.29 - No.1 UNIVERSA MEDICINA INTRODUCTION According to the Population Census of the year 2000, the number of Indonesian women more than 50 years of age and presumably having entered menopausal age was 15.5 million and in the year 2020 it is estimated that the number of women at menopausal age will be 30.3 million or around 11.5% of the total population of Indonesia.(1) Apart from the increasing number of menopausal women as part of the group of elderly people among the Indonesian as well as the world population, there are several other factors that cause the The postmenopausal period plays an important role in women’s life and gives rise to many physical and mental problems. A cross-sectional was conducted to determine the quality of life and its determinants, namely pyschosocial and lifestyle factors in postmenopausal women. One hundred and seventy-six post- menopausal women meeting the inclusion criteria were recruited. The menopause rating scale (MRS) questionnaire was used for the assessment of quality of life. One hundred and thirty-one (74.4%) subjects had complaints related to menopausal symptoms in 3 degrees of severity: mild (38.6%), moderate (30.7%) and severe (5.1%). Urogenital symptoms were the most frequent complaints reported by the subjects (71.6%). The correlation between quality of life of postmenopausal women and several psychosocial and lifestyle factors, namely marital status, education, occupation, knowledge and attitude towards menopause, exercise, smoking and consumption of caffeine and alcohol was statistically not significant (p>0.05). By multiple logistic regression analysis, some of the determinants, such as the subjects’ attitude towards menopause (PR = 2.863; 95% CI: 0.578 – 14.185) and support from the husband and/or family (PR = 2.124; 95% CI: 0.979 – 4.610) did not reach statistical significance, but were still the most influencing factors on their quality of life. Quality of life is worst in postmenopausal women and therefore counseling and support from husband and/or family are needed by the postmenopausal women in order to improve their quality of life. Keywords: Psychosocial, quality of life, postmenopause 35 Univ Med Vol.29 No.1 menopausal problem to be in need of special concern. The declining steroidal hormone levels, especially estrogen, in the female body in the perimenopausal period, not only alters the menstrual pattern but also affects general health, such as is apparent in wrinkled skin, dry vagina (leading to dyspareunia), dysuria, p a l p i t a t i o n s , m i g r a i n e , h o t f l u s h e s a n d i n s o m n i a , c o l l e c t i v e l y k n o w n a s t h e climacteric syndrome. The prevalence of the c l i m a c t e r i c s y n d r o m e i n E u r o p e a n a n d American women ranges from 74 to 87.2%,(2) while in China and other Asian nations the incidence is 10%.(3) The prevalence of hot flushes varies widely across populations and is strongly influenced by culture and ethnicity. In the United States, the Study of Women’s Health Across the Nation (SWAN) surveyed more than 16,000 women and found that the prevalence of hot flushes was highest among A f r i c a n A m e r i c a n s ( 4 6 % ) , f o l l o w e d b y Hispanics (34%), whites (31%), Chinese (21%), and Japanese (18%).(4) Several factors strongly suspected of playing a role in the menopausal experience and quality of life in this period are culture-bound behaviors, such as diet, smoking, and exercise.(5-7) Preventive measures for proactive maintenance of health and vitality that may be taken by women in facing the menopause, as recommended by the International Menopause Society (IMS), relate to healthy behavior and lifestyle, such as exercise, decreased consumption of caffeine, salt, and sugar, reduction or cessation of smoking and alcohol consumption, taking certain vitamins and/or minerals, adequate rest and sleep, consumption of a balanced diet (low i n f a t ) a n d u n d e rg o i n g r e g u l a r h e a l t h checkups. (8) Several longitudinal studies conducted with sufficiently large samples in populations of menopausal women revealed a s u b s t a n t i a l l y s t r o n g r e l e v a n c e b e t w e e n psychosocial factors and biomedical aspects. With the support of healthy behavior and lifestyle, social support of friends and family, the symptoms of menopause may be adequately managed such that medical intervention is unnecessary.(6,7) Quality of life (QOL) does not only relate to problems of physical health or absence of disease, and currently there is no universally accepted definition of “quality of life”. The definition of “quality of life” according to the WHO is the perception of an individual ‘of his/ her position in life in the context of the culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards and concerns’. (9) In the health context, QOL that is related to the impact of illness or health disturbance has a number of situational and conditional aspects in the life of an individual. The menopause rating scale (MRS) is a health-related scale that was d e v e l o p e d i n r e s p o n s e t o t h e l a c k o f standardized scales for measuring the severity of aging symptoms and their impact on the HRQOL in the early 1990s. Actually, the first version of the MRS was to be filled out by the treating physician but methodological critics l e d t o a n e w s c a l e w h i c h c a n e a s i l y b e completed by the women themselves, not by their physician.(10) The aims of the MRS were to enable comparisons of the symptoms of a g i n g b e t w e e n g r o u p s o f w o m e n u n d e r different conditions, to compare severity of symptoms over time, and to measure changes pre- and post-treatment.(11-13) I n m a n y d e v e l o p e d c o u n t r i e s t h e menopausal problem and its symptoms or the climacteric syndrome have become a national health problem. Currently in Indonesia many studies and investigations have started to be conducted on the menopausal problem, but are still limited to the biomedical aspects, such the climacteric syndrome, and lipid profile and osteoporosis in menopausal women.(14-15) The present study was done in order to study the degree of QOL of postmenopausal women and to determine the presence of an association between psycho-social aspects and lifestyle on the one hand and QOL on the other. 36 METHODS Research design T h i s w a s a c r o s s - s e c t i o n a l s t u d y t o determine the presence of an association between psycho-social aspects and lifestyle of Indonesian postmenopausal women and their QOL. The study was performed at the Cilandak District Health Center – South Jakarta from 23 March to 25 April 2009. Subjects of study A total of 176 subjects were recruited by non-probability (or consecutive) sampling in all service units of the Cilandak District Health Center – South Jakarta. All women in the age r a n g e o f 4 5 - 5 9 y e a r s h a v i n g e n t e r e d menopause (with cessation of menstruation of minimally one year) and meeting the inclusion criteria were involved in this study. The inclusion criteria were: literate and healthy women (capable of independently performing daily activities of life and engaging in verbal communication), not on menopause-related hormonal drugs within the previous three months, willing to participate in the study until completion after receiving the necessary information, and willing to sign an informed consent. The exclusion criteria were prior bilateral oophorectomy and/or hysterectomy and non-compliance with the study protocol. Data collection The data collectors conducted interviews by means of a questionnaire comprising questions on sociodemography and economy, knowledge about and attitude towards the menopause, use of hormone replacement therapy and family support, and a number of habits or lifestyles such as exercise, dietary c o m p o s i t i o n , h a b i t u a l c o n s u m p t i o n o f phytoestrogen-containing foods, smoking, consumption of caffeine and alcohol. The HRQOL of the menopausal women were assessed by means of the Indonesian version of the MRS, that had been tested on its validity and reliability in Indonesia, comprising three d i m e n s i o n s o r s u b s c a l e s o f m e n o p a u s a l s y m p t o m s , v i z . p s y c h o l o g i c a l , s o m a t o - vegetative and urogenital.(16,17) This instrument consists of questions on 11 menopausal symptoms, the degree of which is expressed as a number from 0 (no symptoms) up to 4 (extremely severe symptoms), as stated by the subject in question based on her own perception.(14,15) The subject was considered to have no QOL abnormalities if the abnormality was “absent/slight” or if the subject had a total score of 0–4 by MRS assessment criteria. The s u b j e c t w a s c o n s i d e r e d t o h a v e Q O L a b n o r m a l i t i e s i f t h e a b n o r m a l i t y w a s “moderate/severe” or if the subject had a total score of >5 by MRS assessment criteria. Data analysis The study data were analyzed with SPSS (Statistical Package for Social Sciences) version 15.0. Bivariate chi-square tests were used for comparative analysis of each of the independent variables (psychosocial and lifestyle) and the dependent variable (quality of life of menopausal women), both of which were categorical data. The relationships between several independent variables and the dependent variable were analyzed in a multiple logistic regression model. p-value < 0.05 was taken as a cut-off for statistical significance and all tests were 2-sided. RESULTS The subjects recruited into this study totaled 176 women in the age range of 45-59 years, where the youngest subject was 45 years of age and the oldest 59 years, and the mean s u b j e c t a g e w a s 5 3 ± 3 . 4 6 y e a r s . T h e assessment results on the degree of QOL of the subjects conducted by means of the MRS questionnaire showed that 131 (74.4%) of the subjects had QOL abnormalities, comprising mild (38.6%), moderate (30.7%) and severe degrees (5.1%). Wratsangka QOL in postmenopausal women 37 Univ Med Vol.29 No.1 Vi e w e d f r o m t h e a s p e c t s o f t h e abnormalities experienced by the subjects, the u r o g e n i t a l a b n o r m a l i t i e s w e r e t h e m o s t frequently suffered by the subjects (126 women or 71.6%), i.e. abnormalities connected with sexual and urinary (voiding) activities, and m o r e t h a n 5 0 % a m o n g t h e m h a d t h e abnormalities in moderate and severe degrees. Another aspect of the abnormalities that was also experienced by more than half of the subjects related to psychological abnormalities (114 women or 64.7%) and somatovegetative abnormalities (106 women or 60.2%) (Table 2). In this investigation, a study was performed on the relationship of marital status, level of education, occupational status, activities of the subjects outside their occupation, and sources of household finance and health funds on the one hand and QOL on the other. There was no significant difference in the prevalence of QOL abnormalities (p>0.05) between the groups of subjects in marital status, occupational status, activities outside occupation, and household finance and health funds (Table 3). Therefore it may be stated that i n t h i s s t u d y t h e s e s o c i o - e c o n o m i c a n d demographic factors had no relationship with QOL abnormalities in postmenopausal women. In this study there was also no significant d i ff e r e n c e i n t h e p r e v a l e n c e o f Q O L abnormalities (p>0.05) in respect to: (i) knowledge of the subjects about menopause: between the group of subjects who considered menopause to be an illness, those who viewed menopause as a normal/natural process not needing special attention, and those for whom menopause was a natural process with a risk of negative impacts; (ii) attitude of the subjects towards menopause: between the group of subjects with a positive and those with a negative attitude towards menopause (Table 4). As may be seen from Table 5, in this study there was also no significant difference in the prevalence of QOL abnormalities between the various groups of subjects with respect to adequacy of information on the menopause, knowledge of the husband/partner about the menopause and family support in facing the menopause (p>0.05). Degree of quality of life abnormality Absent Mild Moderate Severe Aspect of abnormality n % n % n % n % Psychological 62 35.2 70 39.8 31 17.6 13 7.4 Somato-vegetative 70 39.8 74 42.0 26 14.8 6 3.4 Urogenital 50 28.4 35 19.9 69 39.2 22 12.5 Table 2. Aspect and degree of quality of life abnormality of postmenopausal women Table 1. Assessment criteria of the menopause rating scale (16) Assessment score Quality of life abnormality Psychological subscale Somato-vegetative subscale Urogenital subscale Total Absent/Slight 0 – 1 0 – 2 0 0 – 4 Mild 2 – 3 3 – 4 1 5 – 8 Moderate 4 – 6 5 – 8 2 – 3 9 – 16 Severe > 7 > 9 > 4 > 17 38 There was no significant difference in the prevalence of QOL abnormalities between g r o u p s o f s u b j e c t s w i t h v a r i o u s h a b i t s / lifestyles, such as exercise, consumption of phytoestrogen-containing foods, smoking, and consumption of caffeine and alcohol (p > 0.05). In this study there was a significant difference (p<0.05) in the prevalence of QOL abnormalities between groups of subjects who were always, occasionally, and not at all concerned about a balanced composition (carbohydrate, fat and protein) of their daily diet. In the group of subjects who never were concerned about balanced dietary patterns there were more QOL abnormalities compared with the other groups. Wratsangka QOL in postmenopausal women Table 4. Relationship between knowledge and attitude of subjects on menopause and quality of life abnormalities in postmenopausal women Quality of life abnormality Yes No Psychosocial aspect n % n % p* Prevalence ratio Knowledge about menopause Abnormality/illness Normal/natural process Natural process with risk of negative impact 3 38 15 75.0 25.2 71.4 1 113 6 25.0 74.8 28.6 0.945 Attitude towards menopause Positive Negative 117 14 73.1 87.5 43 2 26.9 12.5 0.339 2.573 (95% CI: 0.561 – 11.789) * Chi-square test * Chi-square test Table 3. Relationship between several sociodemographic and economic factors and quality of life abnormalities in postmenopausal women Degree of quality of life abnormality Yes No Psychosocial aspect n % n % p* Prevalence ratio Marital status Single Married 26 105 76.5 73.1 8 37 23.5 26.9 0.933 0.873 (95% CI: 0.363 –2.098) Level of education Low High 42 89 79.2 72.4 11 34 20.8 27.6 0.440 0.686 (95% CI: 0.317 –1.484) Occupational status Unemployed Employed 62 69 73.8 75.0 22 23 26.2 25.0 0.994 1.065 (95% CI: 0.541 –2.096) Activities outside occupation Absent Present 57 64 77.0 71.9 20 25 23.0 28.1 0.547 0.764 (95% CI: 0.387 –1.509) Source of household finance Own/husband’s salary Retirement funds/other 92 39 76.7 69.6 28 92 23.2 30.4 0.418 0.698 (95% CI: 0.343 –1.419) Source of health funds Insurance/employer support Own funds 55 76 71.4 76.8 22 23 28.6 23.2 0.528 1.322 (95% CI: 0.670 –2.608) 39 Univ Med Vol.29 No.1 Quality of life abnormality Yes No Family factors n % n % p* Adequacy of information on menopause Inadequate Adequate More than adequate 46 77 8 80.7 74.0 53.3 11 27 7 19.3 26.0 46.7 0.096 Knowledge of husband/partner about menopause Abnormality/illness Normal/natural process Natural process with risk of negative impact 4 92 9 80.0 72.4 90.0 1 35 1 20.0 27.6 10.0 0.453 Family support None Poor Adequate 99 2 30 79.2 66.7 62.5 28 1 18 20.8 33.3 37.5 0,075 Table 5. Relationship between family factors and quality of life abnormalities in postmenopausal women * Chi-square test * Chi-square test Table 6. Relationship between lifestyle and quality of life abnormalities in postmenopausal women Quality of life abnormality Yes No Lifestyle n % n % p* Exercise Yes, almost daily Yes, occasionally None at all 23 79 29 74.2 71.8 82.9 8 31 6 25.8 28.2 17.1 0.43 Balanced dietary composition Yes, always Yes, occasionally None at all 16 23 38 62.8 25.8 86.4 27 66 6 37.2 74.2 13.6 0.04 Consumption of phytoestrogen/isoflavone Yes, daily Yes, occasionally None at all 95 35 1 72.5 79.5 100.0 36 9 0 27.5 20.5 0 0.54 Smoking Never In the past, but not now Yes 121 7 3 73.8 87.5 75.0 43 1 1 26.2 12.5 25.0 0.69 Caffeine Yes, daily Yes, occasionally None at all 50 64 17 83.3 72.7 60.7 10 24 11 16.7 27.3 39.3 0.07 Alcohol Yes, daily Yes, occasionally None at all 1 4 126 100.0 57.1 75.0 0 3 42 0 42.9 25.0 0.48 40 Among the 17 variables included in the bivariate selection, there were five with p < 0.25 and meeting the criteria for inclusion in the multivariate analysis, viz. attitude of subjects towards the menopause, adequacy of i n f o r m a t i o n o n t h e m e n o p a u s e , f a m l i t y support, balanced dietary composition and consumption of caffeinated beverages. The v a r i a b l e “ k n o w l e d g e o f s u b j e c t a b o u t menopause” was also included in the bivariate modeling in spite of p>0.25, because it was considered to be very important. Multivariate analysis was performed on several independent variables (psychosocial factors and habit/lifestyle) against the dependent variable (QOL). Prior to this, bivariate selection was done and it was determined that the independent variables with p < 0.25 were to be included in the multivariate logistic regression analysis. In the multivariate analysis, as shown on Table 7, the subjects’ attitude towards the menopause and family support for them in facing the menopausal changes played an important role in their QOL. In the relationship between the subjects’ attitude towards the menopause and QOL abnormalities, a prevalence ratio of 2.863 was found (95% CI: 0.578 – 14.185) between the group of subjects with a negative and those with a positive attitude towards menopause. This means that the subjects with a positive attitude towards menopause had a 2.8-fold greater probability of being free from QOL abnormalities, in comparison with the subjects with a negative attitude towards menopause. In the relationship between family support for the subjects in facing the menopausal changes and the prevalence of QOL abnormalities, prevalence ratios of respectively 2.124 (95% Wratsangka QOL in postmenopausal women Quality of life abnormalities Yes No Independent variable n % n % p* Prevalence ratio Knowledge about menopause Abnormality/illness Normal/natural process Natural process with risk of negative impact 3 38 15 75.0 25.2 71.4 1 113 6 25.0 74.8 28.6 0.767 0.879 0.536 1.087 (95% CI: 0.372-3.177) 0.433 (95% CI: 0.031-6.140) Attitude towards menopause Positive Negative 43 2 26.9 12.5 117 14 73.1 87.5 0.198 2.863 (95% CI: 0.578-14.185) Environmental support None Poor Adequate 99 2 30 79.2 66.7 62.5 28 1 18 20.8 33.3 37.5 0.159 0.057 0.854 2.124 (95% CI: 0.979-4.610) 1.291 (95% CI: 0.085-19.728) Balanced dietary composition Yes, always Yes, occasionally None at all 27 66 38 62.8 74.2 86.4 16 23 6 37.2 25.8 13.6 0.301 0.124 0.328 0.407 (95% CI: 0.130-1.278) 0.595 (95% CI: 0.210-1.684) Caffeinated beverages Yes, daily Yes, occasionally None at all 50 64 17 83.3 72.7 60.7 10 24 11 16.7 27.3 17.0 0.254 0.313 0.099 0.635 (95% CI: 0.263-1.535) 0.390 (95% CI: 0.127-1.193) Table 7. Results of multivariate logistic regression of quality of life by psychosocial aspects and lifestyle in postmenopausal women * Chi-square test 41 Univ Med Vol.29 No.1 CI: 0.979 – 4.610) and 1.291 (95% CI: 0.085 – 19.728) were found between the group of subjects who felt unsupported by their family a n d t h o s e w h o f o u n d t o b e p o o r l y a n d adequately supported. In spite of that, in this study it could not be proven that the factors of no support and poor support constituted risk f a c t o r s f o r Q O L a b n o r m a l i t i e s i n postmenopausal women. DISCUSSION Based on the QOL assessments conducted in the study subjects by means of the MRS questionnaire, a total of 131 (74.4%) subjects were found to have QOL abnormalities in mild, moderate and severe degrees. The majority of the subjects had QOL abnormalities of mild ( 3 8 . 6 % ) a n d m o d e r a t e d e g r e e s ( 3 0 . 7 % ) . Although the prevalence of QOL abnormalities in postmenopausal women as found in this study cannot be generalized and cannot be considered to reflect the overall picture of I n d o n e s i a n p o s t m e n o p a u s a l w o m e n , t h e prevalence rates obtained may presumably increase our alertness to the problems of menopause and may provide the basis for further studies on a larger population. The investigators were unable to find reports of other studies on QOL in postmenopausal Indonesian women, particularly those using the MRS as the measuring instrument of QOL of postmenopausal women. Viewed from the aspect of abnormalities e x p e r i e n c e d b y t h e s u b j e c t s , u r o g e n i t a l abnormalities were the most frequent (71.6%), namely abnormalities related to sexual and urinary (voiding) activities. More than 50% of the subjects had urogenital abnormalities in moderate and severe degrees. The majority of subjects (80.7%) were married and some of them were still engaged in sexual activities w i t h t h e i r h u s b a n d s / p a r t n e r s , s u c h t h a t abnormalities of sexual activities at menopause may affect their QOL. A Turkish study yielded lower fugures, i.e. 10.8% of postmenopausal women had sexual problems, 15.0% urinary p r o b l e m s , a n d 7 . 8 % v a g i n a l d r y n e s s . ( 1 8 ) Results similar to the Turkish study were obtained by Boekitwetan et al. in the elderly, where 19.5% har urinary tract infections.(19) From the psychological aspect most of the subjects (64.8%) also had psychological abnormalities. More than 60% of the subjects involved in the present study had somato- vegetative abnormalities. Hot flushes and night sweats were the most frequently experienced symptoms in postmenopausal women, in association with sleep disturbances, sensory a b n o r m a l i t i e s a n d d e c r e a s e d c o g n i t i v e functions. The Turkish study yielded similar figures for somato-vegetative abnormalities, where hot flushes and sweating amounted to 50.7%, heart problems 22.9%, sleep problems 24.3%, feeling unhappy 22.6% and anxiety 30.7%.(18) These abnormalities may lead to s o c i a l a n d w o r k - r e l a t e d p r o b l e m s , w i t h significantly lowered QOL. The somato- vegetative symptoms frequently cause the menopausal women suffering from them to visit their doctor and be prescribed drugs for treating the complaints, so that ultimately h e a l t h e x p e n d i t u r e s m a y c o n s t i t u t e a socioeconomic burden. In the present study the variables marital status, level of education, occupational status, accessory activities outside work, source of family finance and source of funds for health expenditures were not associated with QOL abnormalities in postmenopausal women. The study results did not reveal the presence of a significant association between marital status and QOL in postmenopausal women. However, a number of studies showed different results, where sociocultural features influence the presence and severity of menopausal symptoms and are not influenced by sociodemographic factors.(20,21) Married subjects still needed sexual functions, such that abnormalities in sexual functions may be uncomfortable to them and disturb their relationship with their husbands. Several prior studies indicated that 42 v a s o m o t o r s y m p t o m s a n d u r o g e n i t a l abnormalities were less frequently found in single (unmarried or widowed) women in comparison with married women.(17) In this study no association was also found between level of education and QOL of postmenopausal women. Most of the subjects (69.9%) had a high level of education (high school and university), and several studies have s h o w n t h a t v a s o m o t o r s y m p t o m s a n d palpitations were found more commonly in less-educated women.(4) The outcomes being evaluated in this study comprised not only v a s o m o t o r a b n o r m a l i t i e s , b u t a l s o Q O L involving other abnormalities, so that they cannot indeed be compared with the results of other studies. In this study no significant difference in QOL was found with regard to: (i) knowledge of the subjects about the menopause, i.e. between the group of subjects who regarded menopause as an illness, menopause as a normal/natural process not needing special attention, and menopause as a natural process with a risk of negative impacts, and (ii) attitude of the subjects towards menopause: between the group of subjects with a positive and those with a negative attitude towards menopause. The menopause is an event in the life of a woman when the menstrual cycle comes to an end, marked by physiological and psychosocial changes in her life. Although the menopause is a normal event in a woman’s life, the individual perceptions are variable and some women need medical assistance to manage the symptoms of menopause. The transition into the menopause is a complex physiological process that is frequently accompanied by accessory effects of the aging process and social adaptation. (22) A number of women experience the climacteric syndrome, in the form of vasomotor, somatic and psychic complaints in the transition period towards menopause or the perimenopausal period. Subsequently there will be an increased risk of degenerative diseases or chronic disorders such as osteoporosis, cardiovascular disease, colorectal cancer and lowered cognitive functions. The menopausal experience is strongly influenced by the perception of the women about the bodily changes and about how the immediate community around her perceives the menopause. The biomedical model of menopause is focused more on the biological aspects of decreased hormonal levels and on identification of climacteric symptoms. The menopause is considered to be characteristically a deficiency disorder that requires treatment in the form of replacement hormonal therapy, thus transforming the w o m a n i n t o a s i c k p a t i e n t , b e c a u s e t h e climacteric symptoms are believed to be associated with estrogen deficiency. This points out the need for dissemination of more accurate and comprehensive information to premenopausal women regarding all aspects of the menopause. The menopausal woman needs support from her neighbourhood in facing the changes taking place in the peri- and post-menopausal periods. In this study it is apparent that the majority (72.2%) of the subjects’ husbands/ partners also consider the menopause to be a n o r m a l a n d n a t u r a l p r o c e s s t h a t w i l l b e experienced by every woman, without realizing the risk of negative impacts due to the lowered estrogen levels, arising in the short term as well as in the long term. Only 5.7% of the subjects’ husbands realized the risk of negative impacts of the menopause that may be experienced by their wife. A l t h o u g h a p p r o x i m a t e l y h a l f o f t h e subjects (59.1%) mentioned the adequacy of sources of information about the menopause, the abovementioned data indicate that most women or their partners did not know about the true nature of the menopause as a natural process with a risk of negative impacts. The majority of the subjects (59.1%) stated that they had adequate information about the menopause, which they obtained from their friends (35.8%) and health personnel (30.7%), Wratsangka QOL in postmenopausal women 43 Univ Med Vol.29 No.1 and for the remainder from popular science books, the printed/electronic media and others. L a c k o f i n i t i a l i n f o r m a t i o n a n d c o r r e c t knowledge of the subjects, their partners or their neighborhood (including health personnel a n d m a s s m e d i a ) a b o u t t h e p r o b l e m s o f menopause was one of the causes of the s u b j e c t s ’ l o w n e e d f o r m o r e a d e q u a t e information regarding the menopause and its future impacts. The majority of the subjects (71%) also did not feel that they received special support from the neigborhood when facing physical and non-physical changes due to the menopause. The community, particularly the women, need to be better informed about the all of the problems of menopause. Doctors and health personnel in general should be able to provide good support and counseling to women regarding the menopause, starting from menopausal symptoms and complaints and their short term as well as long term impacts, the steps that may be taken for managing those complaints and for preventing problems that might occur in the long term as a result of the menopause. Most menopausal women need education, information about the menopause and support from an individual who is willing to listen to them about their experiences.(23) Regular exercise, nutritionally balanced daily diets, and lesser or no consumption of caffeinare important for maintaining a high QOL in menopausal women. Women who exercise regularly and are non-smokers have a better score for positive mood in facing the changes that they experience. Studies have found that physically less active women complain more of postmenopausal neurovegetative symptoms than do women who exercise regularly.(7) Women who exercise regularly have a better mood profile, fewer somatic symptoms and fewer difficulties in concentration in comparison with l e s s p h y s i c a l l y a c t i v e w o m e n . P h y s i c a l excercise is known to be capable of increasing t h e l e v e l s o f â - e n d o r p h i n s , w h i c h a r e neurotransmitters capable of influencing the regulation of body temperature, and it is the levels of â-endorphins that are lowered as a result of reduced estrogen concentrations in menopausal women. In this study no significant difference was found in QOL abnormalities between the groups of subjects who exercise almost daily, exercise occasionally or never exercise (Table 6). In this study habitual exercise was only quantitatively assessed, based on interviews or self-report by the subjects, making it difficult to measure the differences in biological effect of excercise done almost daily, occasionally, or not at all. Phytoestrogens, which are commonly found in the daily food of the Indonesian community, are substances whose structure mimick that of estrogens and are thus capable of binding estrogen estrogen receptors and functioning as selective estrogen receptor modulators (SERM). Several randomized double-blind studies that have been conducted o n t h e i n f l u e n c e o f p h y t o e s t r o g e n s u p p l e m e n t a t i o n r e p o r t e d a s t a t i s t i c a l l y significant reduction in the prevalence of hot flushes in the group of subjects receiving supplemental phytoestrogens.(24,25) With regard to the dietary composition of the subjects, as viewed from the balance between carbohydrate, fat and protein, the important role of dietary fat in the development of menopausal symptoms was indicated by the association between low fat intake and low prevalence of menopausal symptoms in Asian populations, such as Japanese and Chinese women. A high intake of fat is associated with h i g h e r s e r u m l e v e l s o f e s t r o n e a n d dehydroepiandrosterone sulfate (DHEAS) in postmenopausal Japanese women.(26) Differing results were obtained in an interventional trial indicating that a low-fat diet had no effect on s e r u m D H E A S a m o n g p o s t m e n o p a u s a l Australian women.(27) The statistically non-significant difference obtained in the present study may indeed indicate no association between various 44 abovementioned habits/lifestyles and QOL a b n o r m a l i t i e s , o r m a y a l s o b e d u e t o shortcomings of the instrument used in this study, e.g. the qualitative assessment on the independent and dependent variables. The p r e s e n c e o r a b s e n c e o f a s t a t i s t i c a l l y significant difference is not always identical to a clinically significant difference. It is well- known that the probability of obtaining a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i s proportional to the sample size, such that with a larger sample size even extremely small or clinically irrelevant differences may become statistically significant. The results of multivariate analysis showed t h a t t h e s u b j e c t s ’ a t t i t u d e t o w a r d s t h e menopause and family/neighborhood support for them in facing menopausal changes play an important role in their QOL. QOL abnormalities were found with a 2.8-fold greater frequency in subjects with a negative attitude towards menopause, compared with those with a positive attitude. QOL abnormalities in postmenopausal women were also more frequent in the group of subjects who felt totally unsupported by their neighborhood/family in facing menopausal changes, in comparison with those subjects who felt themselves to be poorly supported. In this study both abovementioned factors (negative attitude towards the menopause and lack of neighborhood support) cannot yet be considered r i s k f a c t o r s f o r Q O L a b n o r m a l i t i e s i n postmenopausal women. CONCLUSIONS I n t h i s s t u d y t h e m a j o r i t y o f postmenopausal women had QOL abnormalities and the most commonly experienced symptoms were hot flushes, sweating, heart problems, sleep problems and anxiety. The high percentage of QOL abnormalities among postmenopausal women necessitates adequacy of information and counseling by health personnel on the problems of menopause using a biopsychosocial approach. ACKNOWLEDGEMENTS The investigators gratefully acknowledge the help provided by the Head and Staff of the Cilandak Health Center and the Health Office of South Jakarta in acquiring the necessary licenses and their full support during the conduct of this study. 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