The present study revealed that the average age at menopause among the women in the Geneva camp was 45.38 years which is similar to the findings of the study of Tasnim et al., (37). However, the mean age of menopause in Bangladesh was reported as 48 to 52 years (28, 38) which is higher than the current study. The average age at menopause is found to be 48–49 years in Indian women (20, 39–43) and is 46–51 years in Pakistani women (25) except one study (26) in Pakistan. The mean age at menopause in the present study is lower than in the Indian and Pakistani data. However, our result is similar to the Saudi Arabian (44) and Egyptian data (45). The higher mean age (52–53 years) at menopausal period was reported from developed (46) countries like Canada and USA.
The individual response to menopause and estrogen deficiency differs considerably due to genetic, environmental, and lifestyle factors. Socioeconomic status is one of the factors that could consistently influence women to attain menopause earlier than the expected age. In our study, women from the Geneva camp failed to guess exactly when their menopause occurred. This is because of their poor socioeconomic conditions and they had to take birth control injections for a long time after the birth of one or two children and thus they noticed that their period had been stopped.
Maximum women (65%) of the study had ≤ 10 year's duration of the menopause and 27% had been suffering for 20 years from menopause. It is estimated that the women from the SEA region spend a long time of their life in the postmenopausal period (47). Identifying the health problems at the earliest time would boost the HR- QoL among the women who spend one-third of this life.
In the present study, the MRS measured the QoL (23). The more severe the symptoms, the higher the MRS score and the worse the QoL. In our study, the mean total MRS score was [mean (± SD), 13.96 (± 6.07)] in terms of severity of the complaints, which indicates postmenopausal women had moderate menopausal symptoms (31). Despite taking hormone replacement therapy, the MRS total score was found to be 9 to 21 among the Pakistani postmenopausal women (26) which is similar to our study. The average total score of symptoms was also the same among the Indian (48) and Saudi Arabian (49) postmenopausal women though the results of the present study contradict the Egyptian (32), Ecuador (14) and Saudi Arabian (17) studies.
The higher score of our postmenopausal women was obtained in the psychological domain [mean (± SD), 6.33 (± 3.46)] followed by the somatic domain [mean (± SD), 6.21 (± 3.02)]. These findings are in accordance with Del Prado M et al., (50). The findings of the present study showed that the QoL was moderate among menopausal women. Regarding symptoms, most of the women in the study (90%) reported joint and muscular discomfort; next highest prevalent symptoms were depressive mood (78%), physical and mental exhaustion (76%), irritability (75%), hot flushes, sweating and sleep disorder (71%). Karmakar et al.,(51) conducted a study on quality of life among West Bengal menopausal women showed consistent findings in poor physical stamina (88%), musculoskeletal pain (84%), pain in the neck and headache (76%), and in low back pain (69%). Another study in Kerala (52) showed that 93% of postmenopause women experienced musculoskeletal pain 88% headache, 62.1% numbness in hands and feet, and 61.1% breathing difficulties. Findings from the Agra study (53) said that 70% of the women suffered from muscular and joint pain and 47% from low backache in their menopausal life. Ahlawat et al., (54) indicated that 90%, 44.3% and 67% of women were experiencing joint/muscle pain, hot flashes and fatigue, respectively. Ganapathy T et al.,(47) and Mohamed HA et al., (49) also reported that hot flushes, poor memory, dissatisfaction with their personal life, and low backache were severe menopausal symptoms.
Hot flushes and night sweating are related to the hormonal changes during menopause periods. Joint and muscular discomfort happened due to the deficiency of a balanced diet and calcium-rich food in the diet. This difference might happen due to genetic or socio-cultural diversity and also differences in diet, especially the consumption of phytoestrogen foods (49, 55). Age at menopause, duration of menopause, level of education, and occupation played a significant role in the development of hot flushes, palpitation, sleeping disorder, depressive mood, irritability, anxiety, physical and mental exhaustion and as well as in sexual problems, bladder problems and dryness of vagina among postmenopausal women in the camp. However, the Geneva camp is a very crowded area. Sunlight reached there very little. The illiteracy rate is high (92%) among women, 76% of people from the lower middle class. As a consequence of these, postmenopausal women and their family members have no idea about the importance of a balanced diet and the benefits of calcium and sunlight during middle age. Along with the physiological changes during menopause, the above factors might also reduce the quality of life among these women
The binary logistic regression results also indicated that occupation, marital status, duration of menopause, and blood pressure had a significant role in the three subclasses of the MRS scale. The postmenopause women who were homemakers suffered from hot flushes, palpitation, and sleeping disorder. Widows faced depressive moods, irritability and anxiety. In the present study, more than half (53%) of the postmenopausal women were married, 45% were widows or separated, and only 8% were literate. Divorced women tended to be a significant (p = 0.055) association with depressive mood, irritability, anxiety, and physical and mental exhaustion and literate women positively associated with the psychological symptoms and the association was highly significant (p = 0.0001). Besides this, the women who were suffering menopause > 10 years had significantly (p = 0.016) less sexual problems and dryness of vagina. Due to the hormonal changes, postmenopausal women face difficulties in different phases (56). The decline in estrogen levels and the changes in the ratio of the hormones among postmenopausal women were reported to increase the intensity of depression and somatic symptoms (57). Jarecka K et al., (58) described that, interpersonal relationships play an important role in health behaviors and in adjusting to a new situation, which helps to change in psychosomatic function of women during menopause. Rejection and loneliness, as well as lack of intimacy in relations with the partner, can extend and prolong the time of experienced ailments. The belief that one is loved, important, understood and surrounded by care may improve the symptoms experienced by enabling more effective coping with them and thus contribute to well-being.
In the study, menopausal HR-QoL was reasonably better among women facing menopause > 50 years old. Menopausal women became habituated to psychological stress as their age increased. Education showed a significant role in the excessive level of depressive mood, irritability, anxiety, physical and mental exhaustion. In contrast, different studies (47, 59) showed opposite results. The probable reasons are that educated people tend to have improved life through their healthy behavior, and positive lifestyles. On the other hand, 92% of women were illiterate in our study, and they lived like a refugee in the Geneva camp. In the camps living conditions are unhygienic, water and sanitation systems are inadequate, and they have little chance to explore a better lifestyle.
Women with psychological symptoms fail to have recognized their symptoms of menopause. As we know, in any third-world country, women are the most vulnerable group who have to constantly fight to find their feet. In addition, the condition of women exaggerates if supplemented by diasporic notions like statelessness, displaced, migration and refugee identity. These psychological symptoms may result from physical and psychological stress these women living in the Geneva Camp experience during midlife. Therefore, the women might have over-rated their symptoms as menopausal symptoms when MRS was administered to them.
An active lifestyle helps with physical and emotional well‑being and physically active women have minimal sleep disorders, mood swings, and better cognitive functions. However, 57% of the postmenopausal women in our study were overweight and obese and they were suffering from significant depression, irritability, anxiety, physical and mental tiredness, and increasing blood pressure too. A cross‑sectional survey by Kakkar et al., (25) in India indicated that nonworking and sedentary lifestyle women significantly suffer from higher frequencies of psychosomatic and urogenital disorders, which is in line with our study findings,.
Our findings suggested that the HR-QoL was generally moderate to low among postmenopausal women. The most common menopausal symptoms reported were joint and muscular discomfort, depressive mood, physical and mental exhaustion, irritability, sleep disorder, hot flushes, sweating, anxiety, and sexual problems. Age at menopause, duration of menopause, level of education, and occupation were significantly related to the HR- QoL among women in the Geneva camp.
4.1. Limitations of the study
There are some limitations to our study. Only one camp was selected for the study, whereas there exist 66 camps across Bangladesh. For this, our results could not be generalized. This was a cross-sectional study, so it does not exclude confounding effects of the natural aging process that may influence the experience of symptoms. In addition, the MRS is a self-completing questionnaire; however, assuming that there would be a substantial number of the studied women who did not have formal education interviewer-administrated questionnaire was practiced instead of the self-administrated questionnaire. Moreover, in collecting data, women were asked to provide some retrospective information, such as menopausal symptoms experienced in the preceding 1 month, last menstruation, etc. Hence recall bias was unavoidable, especially for some of the older women who may have had menopause many years before.