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\title{A Cross Sectional Study to Evaluate the Prevalence of Symptoms of Menopause with Special Reference to Osteoporosis in Post Menopausal Women Attending Out Patient Department of a Teaching Medical Institute}
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             \author[1]{Tejal  Poddar}

             \author[2]{Kirti  Bendre}

             \affil[1]{  KJ Somaiya Medical College}

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\date{\small \em Received: 9 December 2015 Accepted: 1 January 2016 Published: 15 January 2016}

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\begin{abstract}
        


Natural menopause is defined by the World Health Organization (WHO) as the ?permanent cessation of menstruation resulting from the loss of ovarian follicular activity,?1. The word is derived from the Greek men (month) and pausis (cessation). This cross sectional study was carried out on the women attending Out Patient Clinic of Gynaecology Department of a teaching medical institute. For this study, sample size of 373 patients was decided as per use of appropriate statistical calculations. An Osteoporosis specific score sheet was designed. A complete physical examination was conducted along with local examination for all patients which included per speculum and per vaginal examination. Special investigations were conducted for all patients to evaluate symptoms such as pap smear, breast examination and Bone Mineral Density. Bone mineral density was measured using DXA scan for the calcaneum bone. We concluded that most common symptom associated with menopausal transition was night sweats followed by muscle and joint pain, psychosexual symptoms and irritability. Bone mineral density test concluded 34.3% of the population were suffering from osteoporosis while 34% were suffering from osteopenia. There is a statistical correlation between BMD and lifestyle pattern. BMD is significantly reduced in the population suffering from symptoms muscle and joint pain. BMD is inversely proportional to the age since menopause. There is an increased risk for fractures among patients who underwent oopherectomy. There is an inverse correlation between BMD and since menopause.

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\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
atural menopause is defined by the World Health Organization (WHO) as the "permanent cessation of menstruation resulting from the loss of ovarian follicular activity," 1 . The word is derived from the Greek men (month) and pausis (cessation). It is the culmination of some 50 years of reproductive aging-a process which unfolds as a continuum from birth through the menopause transition and ovarian senescence. The menopause transition represents a period of dynamic changes in reproductive and non reproductive tissues. The transition from the reproductive to the non-reproductive stage is the result of a reduction in the female hormonal production by the ovaries. This transition is normally not sudden or abrupt, it tends to occur over a period of years, and it is a natural consequence of aging. However, for some women, the accompanying signs and effects that can occur during the menopause transition years can significantly disrupt their daily activities and their sense of well-being.\par
The overall health and well-being of middleaged women have become a major public health concern around the world. More than 80\% of the women experience physical or psychological symptoms in the years when they approach menopause, with various distress and disturbances in their lives, leading to a decrease in the quality of life \hyperref[b1]{2} .\par
All women have more or less similar hormonal changes with menopause. However, the experience of each women is unique and is influenced by age, cultural background, health, type of menopause (spontaneous or surgical), child bearing desires and relationships. Women may view menopause as a major change in their lives either positive such as freedom from troublesome dysmenorrhoea or the need for contraception or negative such as feeling 'old' or loss of child bearing possibilities. Other women may feel that the menopause brings a cessation of sexual pleasure.\par
A total of 130 million Indian women are expected to live beyond the menopause into the old age by 2015. \hyperref[b2]{3} Menopause is emerging as an issue owing to rapid globalization, urbanization, awareness and increase longevity in urban middle aged Indian women.\par
Menopause is a universal reproductive phenomenon but this reproductive landmark is not the same for all women in all cultures. The world population taken together shows a rough mean menopausal age of 40-50 years . \hyperref[b3]{4} As a first step towards the education of women on different aspects to menopausal symptoms and problems, one should have the insight of their problems and its preventive measures. Hence the need to assess the prevalence of menopausal problems and preventive health behaviors among selected groups of women is essential.\par
Menopause and osteoporosis are related to fragility fractures and constitute a major health problem, in terms of both individual suffering and financial costs. Age is also an important factor in the relationship between bone density and the absolute risk for fracture. Older women have a much higher fracture rate than younger women with the same bone density because of increasing risk from other factors, such as bone quality and tendency to fall. \hyperref[b4]{5} Because of the deprivation of estrogen after menopause, women are more vulnerable to bone loss than men and women with early menopause are particularly at risk. 
\section[{II. Materials and Methods}]{II. Materials and Methods}\par
This cross sectional study was carried out on the women attending Out Patient Clinic of Gynaecology Department of a teaching medical institute. For this study, sample size of 373 patients was decided as per use of appropriate statistical calculations. These patients were selected by simple random sampling method. Post menopausal women beyond the age group 40 years attending the gynaecology out patient clinic were included in the study. Patients with age below 40 years or not attained menopause were excluded from the study. The study period was from January 2012 to August 2013.\par
Consent was taken from all the patients participating in the study .A broad Women Health questionnaire to identify mid life health problems was developed, which patients completed. This included complete history taking including age, parity, occupation ,age since menopause, past medical surgical history and specific history concerning menopausal symptoms. Subjects were graded according to their socio economic status according to the Kuppuswami classification. Lifestyle was graded as sedentary and active according to the following definition. Sedentary people were defined in two ways (1) those expending less than 10\% of their leisure time expenditure in activities involving > 4 metabolic equivalents. (2) Those who did not practice any leisure -time physical activity and who also were above the median in the number of hours spent sitting down during leisure time. Metabolic equivalents represent the ratio of energy expended during a physical activity to the metabolic rate sitting quietly, and are independent of body weight.\par
An Osteoporosis specific score sheet was designed. A complete physical examination was conducted along with local examination for all patients which included per speculum and per vaginal examination. Special investigations were conducted for all patients to evaluate symptoms such as pap smear, breast examination and Bone Mineral Density. Bone mineral density was measured using DXA scan for the calcaneum bone. Inferential statistics were given by Mann Whitney test \& other tests of significance. Statistical analysis were executed to correlate between various variables. Sensitivity and specificity of each risk score were ascertained and cut off risk score for identifying osteoporosis and osteopenia were derived by comparing area under curve of each risk score on drawing receiver operational curve. Data was analysed by using SPSS Software version 16.0. 
\section[{III. Results}]{III. Results}\par
The mean age for menopause in our study was 46.21 years, median 45 years with standard deviation of 4.463. Range (39-60) years .The mean age of our population was 52 years range (42-90years)\par
In our study 7.2 \% population had surgical menopause rest all attained natural menopause.\par
In our study 36.5 \% population had a previous medical history which included 136 persons among the study group. Rest of the population had no significant past medical history. Graph 2 : Comorbid conditions associated with the study population\par
In the study maximum co-morbidity that was seen in population was hypertension (73.53\%) followed by diabetes mellitus (40.44\%) and least was seen to be arthritis (2.21\%) and tuberculosis (2.21\%). 
\section[{Series1}]{Series1}\par
Yes 136 36\%   Total 365 women experienced 1460 all symptoms.
\begin{quote}
Series1\end{quote}
\par
In our study 36.5 \% population had a previous medical history which included 136 persons among the study group. Rest of the population had no significant past medical history.  This table shows that the mean for all osteoporotic patient BMD is -2.82 with standard deviation of 0.22 whereas for osteopenia the mean is -1.64 and standard deviation is 0.398 and for normal patients mean was 0.819 and standard deviation was 0.651. Graph 4 : Distribution of BMD among patients who underwent surgical menopause Among the 27 patients who had surgical menopause 33.33\% population had osteoporosis 37.03\% had osteopenia and 29.62\% were having normal BMD scores. This table is a correlation between surgical menopause and BMD where 27 subjects in the study group underwent surgical menopause, rest all had natural menopause. Among the 27 subjects who underwent surgical menopause 10 had osteopenia 9 had osteoporosis and 8 were normal. When this data was analyzed using Mann Whitney test, it was found that it is statistically not significant as p value is 0.401. This is a correlation between BMD and lifestyle. Among the 272 patients who had active lifestyle 34.6\% hsd osteoporosis and 35.7\% had osteopenia while among the 101 patients who had sedentary lifestyle 33.7\% had osteoporosis and 29.7\% had osteopenia. When this data was entered and analysed by Chi Square test is was found to be not significant.  This table is a correlation between symptoms of muscle and joint pain and BMD. In our study group 90 patients who had muscle and joint pain were showed to have osteoporosis and 64 patients had osteopenia. On analysis of this data using Man Whitney test it was found that this was a statistically significant correlation as p value is 0.001 
\section[{IV. Discussion}]{IV. Discussion}\par
The mean age at menopause observed in our study was 46.21 years. A wide range in mean age at menopause in Indian women from 40.32 to 48.84yrs \hyperref[b5]{[6]}\hyperref[b6]{[7]}\hyperref[b7]{[8]}\hyperref[b8]{[9]}\hyperref[b9]{[10]}\hyperref[b10]{[11]}\hyperref[b11]{[12]}\hyperref[b12]{[13]}\hyperref[b13]{[14]}\hyperref[b14]{[15]} and in developed countries from 48.0 to 51 yrs  {\ref 12-15.} have been suggested in the past.\par
According to our study symptoms such as hot flushes, night sweats, vulvovaginal, psychosexual and muscle and joint pain were seen maximum in low socio economic group Chowta et al., \hyperref[b15]{16} showed that the vasomotor symptoms were more common (89\%) in the lower socioeconomic group, Genitourinary and psychological symptoms were common in the middle socioeconomic group which were similar to our results. In agreement to our study results, the results of Kaulagekar \hyperref[b16]{17} showed that the high-income group had reported more vasomotor symptoms (54 vs 49\%). It also showed that the psychological symptoms were reported more (70\%) among the low-income group than the highincome group (59\%). This could be because of the several other stressors which were present in their living environment. The Study of Women's Health across the Nation (SWAN) results showed that most of the indicators of the low socioeconomic status, particularly the low educational level and the difficulty in paying for the basic necessities, were associated with a significantly increased reporting of almost all the postmenopausal symptoms. Vasomotor symptoms such as hot flushes occured in 36\% of the population in our study group which were similar to studies conducted by Chowta et al in the year 2008 which had 42\%. Urogenital symptoms such as stress incontinence were seen in as many as 5.4\% of the study group .Comparable studies showed siginificantly higher population affected by similar symptoms. Psychological symptoms such as sleep disturbances were seen in 35.7\% of the study population comparable to studies conducted by Chowta et al. Lethargy as a symptom was seen in 37.8\% of our study population. Other studies showed siginificantly higher population affected by this symptom. Muscle and joint pain occurred in 51.2\% of the study populatation which were similar to results from other studies such as Chowta et al (48\%).\par
Studies conducted by Siris ES \hyperref[b17]{18} in the year 2001 showed that the risk for fracture increased as time since menopause increased. Relative risk for time since menopause for 10-19 years was 1.18 (1.01-1.38), 20-29 years was 1.31 (1.12-1.54) and 30 years was 1.51 (1.26-1.81)  {\ref 98} In our study as well relative risk for fractures increases as age since menopause increases. This is because there is a inverse correlation between BMD and since menopause.\par
Lastly studies conducted by Tuppurainen M et al in the year 1995 showed that relative risk for fracture after Oophorectomy was 3.64 (1.01-13.04) \hyperref[b18]{19} In our population 27 patients underwent surgical menopause with oopherectomy. Among them 33\% had osteoporosis and 37\% had osteopenia. Therefore there is an increased risk for fractures among patients who underwent oopherectomy. 
\section[{V. Conclusion}]{V. Conclusion}\par
We found that the majority of the middle aged women in our study viewed the menopausal transition as a natural process, the nature of which is affected by both hormonal changes and by ageing. Each woman seems to experience a set of psychological and physical symptoms that are in some sense unique to her experience. Hypertension was the most common comorbid condition seen along with menopause Most common symptom associated with menopausal transition was night sweats followed by muscle and joint pain, psychosexual symptoms and irritability. Bone mineral density test concluded 34.3\% of the population were suffering from osteoporosis while 34\% were suffering from osteopenia. There is a statistical correlation between BMD and lifestyle pattern. BMD is significantly reduced in the population suffering from symptoms muscle and joint pain. BMD is inversely proportional to the age since menopause. There is an increased risk for fractures among patients who underwent oopherectomy. There is an inverse correlation between BMD and since menopause. \begin{figure}[htbp]
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\noindent\textbf{}\includegraphics[]{image-4.png}
\caption{\label{fig_2}A}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-5.png}
\caption{\label{fig_3}A}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.18214285714285713\textwidth}P{0.12142857142857141\textwidth}P{0.3157142857142857\textwidth}P{0.23071428571428568\textwidth}}
\tabcellsep \tabcellsep \multicolumn{2}{l}{Count Column N \%}\\
\tabcellsep Yes\tabcellsep 136\tabcellsep 36.5\%\\
Medical history\tabcellsep No\tabcellsep 237\tabcellsep 63.5\%\\
\tabcellsep Total\tabcellsep 373\tabcellsep 100.0\%\end{longtable} \par
  {\small\itshape [Note: Graph 1: Medical co-morbid conditions in the study population]} 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.35\textwidth}P{0.18571428571428572\textwidth}P{0.3142857142857143\textwidth}}
\tabcellsep \multicolumn{2}{l}{Count Column N\%}\\
HTN\tabcellsep 100\tabcellsep 73.53\%\\
DM\tabcellsep 55\tabcellsep 40.44\%\\
Heart disease\tabcellsep 9\tabcellsep 6.62\%\\
Hypothyroidism\tabcellsep 7\tabcellsep 5.15\%\\
Asthma\tabcellsep 4\tabcellsep 2.94\%\\
Arthritis\tabcellsep 3\tabcellsep 2.21\%\\
TB\tabcellsep 3\tabcellsep 2.21\%\end{longtable} \par
  {\small\itshape [Note: Percentages exceed 100\% as more than one disease was present among study subjects.]} 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.5876953125\textwidth}P{0.0763671875\textwidth}P{0.11953124999999999\textwidth}P{0.06640625\textwidth}}
\tabcellsep \tabcellsep \multicolumn{2}{l}{Responses Percent of Cases}\\
Vasomotor a\tabcellsep Hot flushes Night sweat\tabcellsep 133 250\tabcellsep 51.4\% 96.5\%\\
\multicolumn{2}{l}{Total}\tabcellsep 383\tabcellsep 147.9\%\\
\multicolumn{2}{l}{Percentages may exceed 100\%}\tabcellsep \tabcellsep \\
\multicolumn{4}{l}{Total 291 women experienced 444 psychological symptoms.45.7\% had sleep disturbances, 48.5\% had}\\
lethargy and 58.4\% had irritability.\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.5922131147540983\textwidth}P{0.08360655737704918\textwidth}P{0.17418032786885246\textwidth}}
Psychological Sleep disturbances\tabcellsep 133\tabcellsep 45.7\%\\
Lethargy\tabcellsep 141\tabcellsep 48.5\%\\
Irritability\tabcellsep 170\tabcellsep 58.4\%\\
Total\tabcellsep 444\tabcellsep 152.6\%\\
Percentages may exceed 100\%\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.265625\textwidth}P{0.584375\textwidth}}
Count\tabcellsep Column N \%\end{longtable} \par
 
\caption{\label{tab_4}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.306\textwidth}P{0.544\textwidth}}
Responses\tabcellsep Percent of Cases\end{longtable} \par
  {\small\itshape [Note: E A Cross Sectional Study to Evaluate the Prevalence of Symptoms of Menopause with Special Reference to Osteoporosis in Post Menopausal Women Attending Out Patient Department of a Teaching Medical Institute]} 
\caption{\label{tab_5}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7} \par 
\begin{longtable}{P{0.027717391304347826\textwidth}P{0.31413043478260866\textwidth}P{0.16630434782608697\textwidth}P{0.3418478260869565\textwidth}}
\tabcellsep \tabcellsep Count\tabcellsep Column N \%\\
\tabcellsep Osteoporosis\tabcellsep 128\tabcellsep 34.3\%\\
BMD\tabcellsep Osteopenia Normal\tabcellsep 127 118\tabcellsep 34.0\% 31.6\%\\
\tabcellsep Total\tabcellsep 373\tabcellsep 100.0\%\end{longtable} \par
  {\small\itshape [Note: Graph 3 : Report of Bone Mineral Density examination Bone Mineral Density test showed that 34.3\% had osteoporosis while 34.\% had osteopenia rest all were normal]} 
\caption{\label{tab_6}Table 7 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{8} \par 
\begin{longtable}{P{0.4146341463414634\textwidth}P{0.13821138211382114\textwidth}P{0.02764227642276423\textwidth}P{0.26951219512195124\textwidth}}
BMD\tabcellsep Mean\tabcellsep N\tabcellsep Std. Deviation\\
\multicolumn{3}{l}{Osteoporosis -2.8211 128}\tabcellsep .22047\\
\multicolumn{3}{l}{Osteopenia -1.6451 127}\tabcellsep .39867\\
Normal\tabcellsep .8191\tabcellsep 118\tabcellsep .65153\\
Total\tabcellsep \multicolumn{2}{l}{-1.2691 373}\tabcellsep 1.56976\end{longtable} \par
 
\caption{\label{tab_7}Table 8 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{9} \par 
\begin{longtable}{P{0.1660919540229885\textwidth}P{0.2735632183908046\textwidth}P{0.08793103448275862\textwidth}P{0.32241379310344825\textwidth}}
\tabcellsep \tabcellsep Count\tabcellsep Column N \%\\
\tabcellsep osteoporosis\tabcellsep 9\tabcellsep 33.33\%\\
Post hysterectomy\tabcellsep osteopenia\tabcellsep 10\tabcellsep 37.037\%\\
\tabcellsep normal\tabcellsep 8\tabcellsep 29.62\%\end{longtable} \par
  {\small\itshape [Note: 5 Volume XVI Issue II Version I © 2016 Global Journals Inc. (US)E]} 
\caption{\label{tab_8}Table 9 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{10} \par 
\begin{longtable}{P{0.4140463917525773\textwidth}P{0.06791237113402061\textwidth}P{0.03286082474226804\textwidth}P{0.26288659793814434\textwidth}P{0.0722938144329897\textwidth}}
\tabcellsep \tabcellsep \multicolumn{2}{l}{Age}\tabcellsep Age Since Menopause\\
\tabcellsep Correlation Coefficient\tabcellsep \multicolumn{2}{l}{-.043}\tabcellsep -.105 *\\
BMD\tabcellsep P value\tabcellsep \multicolumn{2}{l}{.413}\tabcellsep .043\\
\tabcellsep N\tabcellsep 373\tabcellsep \tabcellsep 373\\
\multicolumn{3}{l}{This table shows the correlation between BMD}\tabcellsep \multicolumn{2}{l}{-.0105 which means they are inversely proportional}\\
\multicolumn{3}{l}{and age which is -0.43 which means age and BMD are}\tabcellsep \multicolumn{2}{l}{coefficients. This is not statistically significant as p value}\\
\multicolumn{3}{l}{inversely proportional .Similar results are}\tabcellsep \multicolumn{2}{l}{is 0.413}\\
\multicolumn{3}{l}{seen between BMD and age since menopause which is}\tabcellsep \end{longtable} \par
 
\caption{\label{tab_9}Table 10 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{11} \par 
\begin{longtable}{P{0.028651685393258425\textwidth}P{0.2292134831460674\textwidth}P{0.1146067415730337\textwidth}P{0.2101123595505618\textwidth}P{0.26741573033707866\textwidth}}
\tabcellsep \tabcellsep Ranks\tabcellsep \tabcellsep \\
\tabcellsep Surgical menopause\tabcellsep N\tabcellsep Mean Rank\tabcellsep Sum of Ranks\\
BMD\tabcellsep Yes No\tabcellsep 27 346\tabcellsep 203.76 185.69\tabcellsep 5501.50 64249.50\end{longtable} \par
 
\caption{\label{tab_10}Table 11 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{12} \par 
\begin{longtable}{P{0.015454545454545453\textwidth}P{0.17515151515151514\textwidth}P{0.07727272727272727\textwidth}P{0.2678787878787878\textwidth}P{0.07727272727272727\textwidth}P{0.23696969696969697\textwidth}}
\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{LIFESTYLE}\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep Active\tabcellsep \tabcellsep Sedentary\\
\tabcellsep \tabcellsep Count\tabcellsep Column N \%\tabcellsep Count\tabcellsep Column N \%\\
\tabcellsep Osteoporosis\tabcellsep 94\tabcellsep 34.6\%\tabcellsep 34\tabcellsep 33.7\%\\
BMD\tabcellsep Osteopenia Normal\tabcellsep 97 81\tabcellsep 35.7\% 29.8\%\tabcellsep 30 37\tabcellsep 29.7\% 36.6\%\\
\tabcellsep Total\tabcellsep 272\tabcellsep 100.0\%\tabcellsep 101\tabcellsep 100.0\%\end{longtable} \par
 
\caption{\label{tab_11}Table 12 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{13} \par 
\begin{longtable}{P{0.014825581395348836\textwidth}P{0.16802325581395347\textwidth}P{0.07412790697674419\textwidth}P{0.301453488372093\textwidth}P{0.07412790697674419\textwidth}P{0.2174418604651163\textwidth}}
\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{Muscle /joint pain}\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep Absent\tabcellsep \tabcellsep Present\\
\tabcellsep \tabcellsep Count\tabcellsep Column N \%\tabcellsep Count\tabcellsep Column N \%\\
\tabcellsep Osteoporosis\tabcellsep 38\tabcellsep 20.9\%\tabcellsep 90\tabcellsep 47.1\%\\
BMD\tabcellsep Osteopenia Normal\tabcellsep 63 81\tabcellsep 34.6\% 44.5\%\tabcellsep 64 37\tabcellsep 33.5\% 19.4\%\\
\tabcellsep Total\tabcellsep 182\tabcellsep 100.0\%\tabcellsep 191\tabcellsep 100.0\%\end{longtable} \par
 
\caption{\label{tab_12}Table 13 :}\end{figure}
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\end{document}
