Exploring the relationship between menopausal symptoms, personality, and depressive symptoms in postmenopausal women

Background A quick look at the results of research studies in the existing literature indicates that depression in postmenopausal women can greatly affect their function and self-esteem. The aim of the present study was to explore the potential relationships between menopausal symptoms, sleep quality, hot ash, and depressive symptoms in postmenopausal women. Methods A cross-sectional study was designed with 150 healthy postmenopausal women (45–60 years of age) who had referred to the menopausal clinic in Babol. The participants completed the following instruments throughout the study: the Beck Depression Inventory for depressive symptoms, the Modied Blatt-Kupperman Menopausal Index for measuring menopausal symptoms, and the NEO-FFI for identifying the personality traits. Results After controlling all the covariates, high depressive symptoms were found to be associated with moderate/ sever menopausal symptoms, poor sleep quality, and the average and high level of neuroticism. The results also demonstrated that the risk of depressive symptoms was lower in menopausal women with high level extroversion, high level agreeableness, and the average and high level of conscientiousness. Conclusions The ndings of the present study indicated that personality traits, menopausal symptoms, and poor sleep quality in particular can partially account for depression in Iranian menopausal women.


Background
Menopause is a normal event experienced in every woman's life [1]. It is widely accepted that it occurs to women around 40-58 years of age all over the globe [2,3]. Research ndings illustrate that Iranian women generally reach menopause around 48 years of age [4] and commonly experience many different symptoms such as vasomotor, psychological, and somatic symptoms, which could be due to the sudden decline of estrogen level [5][6][7][8]. It is generally assumed that the severity and frequency of menopausal symptoms could be different for each woman [9]. Survey results indicate that psychological disorders such as depression, anxiety, and di culties in coping with stress are more prevalent around the age of menopause menopausal women [10,11]. The mean age for the prevalence of depression is supposedly 40, and it is most likely to occur around the age of menopause [12,13]. It is evident that depression could have adverse effects on interpersonal relationships, social, occupational, and sexual function of women; thus, it, according to research ndings, could have serious consequences for 34% of postmenopausal women [14,15].
It is also presumed that personality traits could tremendously affect the severity of the menopausal symptoms [16]. Given that the relationship between personality traits and the severity of menopausal symptoms is somehow vague, several studies have already tried to explore and substantiate this relationship [17,18]. It is widely thought that personality traits can re ect the cognition, emotions, and the behavioral tendencies of individuals in various circumstances. Although there are numerous personality traits, only a few of them have been investigated by scholars during menopause with regard to depression [19,20]. For instance, the results of a study conducted by Sassoon et al. demonstrated that individuals with personality disorders were more likely to have shown episodes of menopausal symptoms and depression [21].
There are, nevertheless, many reports with contradictory results about the relationship between menopausal symptoms and depression. Despite the positive interest, it can be postulated that the role of personality traits and menopausal symptoms in the development of depression is poorly understood and inadequately researched in Iranian context. Hence, in the light of these concerns, it is imperative that both personality and menopausal symptoms, especially poor sleep and hot ash factors leading to the development of depression symptoms, be investigated for women around menopause women. Such results, if achieved, could help prevent and manage depression by providing the necessary interventions and guidelines.

Methods
This study adopted a cross-sectional descriptive design to collect information exploring the potential relationships between menopausal symptoms, sleep quality, hot ash, and depressive symptoms in postmenopausal women. This research was additionally approved by the ethics committee of Babol University of Medical Sciences (Ethic ID: IR. MUBABOL.HRI.REC. 1397. 032). The inclusion criteria for the study were as follows: The participants had to be around 45-60 years of age, and they had to have experienced their last menstruation at least one year prior to the study. It is also worth noting that women with a history of surgical menopause, abnormal cervical smear test, chronic diseases, endometrial or ovarian cancer or breast cancer, thyroid dysfunction, anti-psychotic drug use, hormone replacement therapy during the last six months, and smoking habits or alcohol use were excluded from the study. Any interested menopausal women around 45-60 years of age who referred to the menopausal clinic a liated with Babol University of Medical Sciences over the period between September 2016 and August 2018 were recruited for this study. We totally recruited 189 women (age range 45-60) for this study, out of whom 31 were excluded, and 158 proved to be eligible for the purpose of this study. Before the outset of the research, informed written consents were obtained from all the participants. Then the participants were asked to complete the questionnaires for the study. Eight questionnaires were excluded due to missing information, and the remaining data from the 150 women were used for the nal analysis.
The instruments for this study were: The traits data; the Beck Depression Inventory (BDI), used for assessing depressive symptoms [22]; Modi ed Blatt-Kupperman Menopausal Index (MKMI), measuring the severity of climacteric symptoms [23]; and Five Factor Inventory (NEO-FFI), used for the assessment of personality traits [24].
The participants' age, education, marital status, parity, working status, monthly family income, and cigarette use were obtained from the questionnaire. The participants' weight was measured using digital scales with minimal dress and without shoes. The height was recorded with a tape. The BMI was computed using the formula weight (kg)/height2 (m). The waist circumference was measured to the nearest 1 centimeter using a tape measure at the level midway between the lower rib margin and iliac crest.
Beck Depression Inventory (BDI): BDI is a standard tool, widely used in numerous studies measuring physical, behavioral, and cognitive symptoms of depression. This questionnaire comprises 13 items, each substance has 4 options, scaling down from 0 to 3, and it sets various degrees of depression from mild to severe. The maximum score in this test is 63, and the minimum is zero [22]. The reliability and validity of this questionnaire was reported by a study conducted by Rajabi. The questionnaire had been used to screen depression in psychiatric outpatients in Iran [25].
NEO Five-Factor Inventory (NEO-FFI): The NEO-FFI is one of the most widely used instruments to assess personality traits on ve dimensions: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness through 60 questions. NEO-FFI is scored based on a 5-point Likert's scale (strongly disagree, disagree, no idea, agree, and strongly agree) , and the questions are scored from 0 to 5. It is worth mentioning that reverse-coding needs to be considered for some questions [24]. The reliability of the NEO-FFI had already been con rmed by Garousi et al. in Iran. They reported Cronbach alpha coe cients of 0.86, 0.73, 0.56, 0.68, and 0.87 for neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness, respectively [26].
Modi ed Blatt-Kupperman Menopausal Index (MKMI): The Climacteric symptoms were assessed through the 13-item MKMI. It should be mentioned that urinary infection was added to the modi ed version, and libido was reduced from the original KI. It comprises the following 13 components: hot ash and night sweats, paresthesia, insomnia, nervousness, melancholia, vertigo, fatigue, arthralgia, myalgia, headache, heart palpitation, formication, sexual complaints, and urinary tract infection. Each symptom on the MKMI was rated from 0 to 3 for no, slight, moderate, and severe complaints. To calculate the MKMI, the weighted score for hot ashes/sweating was 4 points; paresthesia, insomnia, mood swings, sexual problems, and urinary tract infection were 2 points each; and the other symptoms were 1 point each. The total scores ranged from 0 to 63. Scores ranging from 0-6, 7-15, 16-30, and 30 were used to rate the degree of severity as none, mild, moderate, and severe, respectively [23]. The validity of MKMI had already been con rmed by Mohammadi et al., in Iran [27].

Statistical analyses
The data were analyzed using statistical package of computer software (SPSS) 20.0. Chi-square test was used to examine the characteristics of the participants: women without depression and those with depression. Logistic regressions were run to assess the relationships between variables, related to depressive symptoms at p = 0.2 in the bivariate analyses. Odds ratios associated with 95% con dence intervals (CIs) were computed using logistic regression. The p-value of 0.05 or less was considered signi cant in all tests.

Results
A total of 150 post-menopausal women (with a mean age of 54.1 ± 3.6 years, ranging 45-60 years of age) were enrolled. Moderate/ sever menopausal symptoms were observed in 72.0% of the participants.
The prevalence of hot ash and poor sleep were 72.7% and 24.0%, respectively. According to NEO-FFI, high levels of neuroticism were observed in 30.7% of the participants. The prevalence of low levels of extroversion, openness to experience, agreeableness, and conscientiousness were 21.3%, 74.0%, 41.7%, and 7.3%, respectively. The overall prevalence depressive symptoms in menopausal women (45-60 years of age) were 53.3%, measured by the Beck Depression Inventory. The participants were divided into two groups in terms of traits: depressed and non-depressed. The participants with depressive symptom were more likely to rate lower education status (p = 0.025) and their monthly family income was low (p = 0.007). There were no statistically signi cant differences found between the age, marital status, parity, working status, BMI, waist circumference or cigarette use of women with and without depressive symptoms (Table 1).

Discussion
The ndings of this study demonstrated that depressive symptoms in postmenopausal women were associated with the severity of menopause, even after controlling the covariate variables. This nding is consistent with those of other studies reporting that depressive symptoms positively correlated with severity of menopausal symptoms [28,29]. We also found that poor sleep was associated with depressive symptoms in postmenopausal women. This nding is also in line with those of several other studies substantiating the association between poor sleep and depressive symptoms [30][31][32][33]. Nonetheless, contrary to other studies, we found that having hot ash was not associated with depressive symptoms [30,32,34]. This discrepancy in result could be attributed to the different age of the participants in our study.
Moderate/severe hot ashes are usually observed for four to ve years after the menopause [35]. 45.3% of the participants in our study, however, reported that the nal menstrual period occurred to them in the last 5 years or longer. In addition, our nding is congruous with studies reporting no association between depressive symptoms and hot ashes [12,36].
It is imperative to gure out as to whether personality trait could predict depression in postmenopausal women. Among personality traits, neuroticism is supposedly a vital trait which could predict the severity of menopausal symptoms (33). Our nding depicted that women with average and high neuroticism traits could be more vulnerable to depressive symptoms. This nding is consistent with the result of a community study conducted by Chou et al. on 190 middle-aged women and demonstrated the positive correlation between neuroticism and depressive symptoms [12]. A possible explanation for the causal relationship between neuroticism and the severity of depression is that neuroticism can lead to irrational thinking in postmenopausal women, which may amplify negative attitudes toward the body and encourage them to seek an indication of illness [37]. Moreover, it is worth mentioning that neuroticism can substantially strengthen the response to internal and external anxieties [35]. It can consequently engender negative attitudes due to natural changes occurring during the menopause, which can ultimately lead to an increased risk of depression [16].
Furthermore, our ndings depicted that other personality traits such as high level extroversion, high level agreeableness, and the average and high level of conscientiousness tend to lower the depressive symptoms in menopausal women. Numerous research studies have already con rmed the relationship between personality traits and depressive symptoms [38][39][40]; there are several studies, however, failing to support this relationship [41][42][43]. They, as a matter of fact, reported that changes in depressive symptoms were not necessarily related to those of the personality traits [44,45].
As for the limitations, this study had several limitations: rst, this study used a self-report questionnaire to determine the symptoms of menopause, personality traits, and depression, which may have induced some kind of response bias. Other limitations of the study were the small sample size as well as access to participants.
Despite the limitations, the study had a number of strengths. It enjoyed a community-based design and made use of wide inclusion and exclusion criteria to screen the participants. The study covered the midlife age group only (45-60 years) and used valid instruments to assess menopausal symptoms. The most noticeable merit of the study was the recruitment of healthy women and the exclusion of those with chorionic diseases.

Conclusion
The results of this study indicated that depression was associated with menopausal symptoms, poor sleep, and personality traits in Iranian menopausal women. The study also depicted that neuroticism could serve as a predictor of depression in menopausal women. Hence, it can be concluded that the use of screening for the identi cation of the personality traits could greatly contribute to hinder depression. It is highly imperative that the staff at menopausal clinics pay adequate heed to menopausal women with sever menopausal symptoms, poor sleep, or neuroticism and implement appropriate strategies to improve the quality of life for these women.