The findings of the present study on women’s experiences of menopause in Sri Lanka show that menopause is perceived as a stage of the normal aging process. This finding is consistent with findings from other research studies on women mainly derived from collectivist cultures such as those of Jordan [22], Korea [23], and Thailand [24], and from Hilo women in Hawaii, for whom aging has a positive significance. The findings of this study could therefore be explained from a sociocultural perspective, where positive attitudes about menopause are not uncommon in cultures where aging comes with increased social status, thus risking a low rate of reported menopausal symptoms [7]. After all, the women in the current study experienced menopausal physical and mental changes with unpleasant symptoms, as seen in the category Entering a new stage in life, similar to other women around the world [25]. However, coping with menopausal symptoms may be different for women in different parts of the world, as culture has been found to affect perceptions towards menopause [6]. Women in this study handled their symptoms mainly through self-care that consisted of non-pharmacological methods such as use of local herbs, and religious activities. Only a few women in this study had experienced HRT, which is reasonable, as HRT is not common in Sri Lanka, partly due to lack of credible information about hormonal therapy, according to the Menopause Society of Sri Lanka [15].
The women in the current study mainly were Buddhists who followed Buddhist teachings about the life cycle consisting of birth, aging, illness, and death, which may have contributed to their perceiving menopause as a natural consequence of the normal aging process. This conclusion accords with Noonil et al. (2012), who studied the lived experience of Thai Buddhist women and their changing bodies in midlife [24]. The perception of menopause as a natural component of the life cycle may, however, contribute to ignoring menopausal health risks or delaying necessary treatment until too late a stage. This perception may also explain why Waidyasekera et al. (2009) found that women in Sri Lanka had a significantly decreased health-related quality of life due to menopausal symptoms, as one or more menopausal symptoms were significantly associated with chronic illnesses [14]. Self-care, which per se is desirable from a health-promotive perspective, could therefore in the worst-case scenario delay prevention and detection of any menopausal health-related issue and its timely treatment.
Health-seeking behavior related to menopause may further be jeopardized, as the women in this study viewed themselves as equally important in taking care of their families after menopause as before, as seen in the category Remaining valuable. Culturally, Sri Lanka is a collectivistic culture [26] with deep and strong family inter-relationships, where women traditionally have the main responsibility for looking after the home and the children. The risk of ignoring menopausal symptoms is therefore further empathized by living in a family-oriented culture in which a woman upholds her value by giving priority to the daily care of her family members. This conclusion is strengthened by Im and Meleis [27], who studied Korean immigrant women’s experiences of menopause and found that these women did not pay much attention to menopausal issues, as they devoted their time and energy to meeting daily demands influenced by the heritage of their country of origin. The culture of Sri Lanka being family-centered, it is not surprisingly that the result emphasizes the importance of women being part of a small group that provides the security needed not only to discuss intimate and personal matters like menopausal health issues but also to receive support to help them face losses of close relatives. This finding corroborates the findings of Noonil et al. (2012) and Mackey (2014), who highlighted the importance of women sharing their experiences to overcome any changes during the menopausal transition [28] and of support groups for middle-aged women to share their menopausal experiences to increase self-awareness in managing self-care measures and health care interventions [2]. Thus, enabling support groups for menopausal women could facilitate the menopausal transition as well as strengthen the individual.
According to Meleis (2010), women’s understanding about menopausal changes is essential, as the level of engagement of a person who is aware of physical, emotional, social, or environmental changes will differ from that of a person who is unaware of such changes [27]. The women in the present study were aware of the physical transition from being fertile to becoming infertile, as shown in the category Entering a new stage in life. However, while stressing the importance of seeking treatment for menopause symptoms, the women placed responsibility for their families above seeking help to overcome menopausal discomfort during the transition to menopause. This conclusion confirms that Sri Lankan women’s health-seeking behavior related to menopausal changes is dependent on a busy life, mainly due to family involvement [15]. Thus, it seems vital to encourage Sri Lankan women to nevertheless take part in screening, as they are likely to ignore serious symptoms because they prioritize family obligations instead of seeking health care for themselves.
Transition is a concept of importance for nursing, as transition is a process of change, which may give rise to emotional distress due to loss of control related to the change and its outcomes [27]. However, the concept of culture is as important for nursing, as it impacts the way individuals respond to change and how they cope up with the consequences of the change. In other words, from a cultural perspective, menopause seems to have a natural place in the aging process of the woman, making the menopausal symptoms easier to handle; at the same time, there is a risk of normalizing and ignoring menopausal symptoms, thereby leading women to suffer in silence. Moreover, the detection of menopause-related health risks such as cervical and breast cancer may be ignored because of this attitude, despite women’s awareness of the importance of attending to menopausal symptoms and related-health risks. However, not all aspects of menopause can be explained by culture, as seen in the category Entering a new stage in life, in which women in the present study described menopause as a relief from the risk of becoming pregnant, a finding that corresponds to a study on Jordanian women, who described menopause as “a life transition” resulting in freedom and relief from reproductive obligations [2].
Limitations
The issue of accuracy needs to be recognized in all qualitative studies presenting the results in a language other than the native language. All the interviews were conducted in Sinhalese and transcribed into English by the first author (IMPS), who is familiar with the cultural interview norms and expectations. The author (IMPS) who did all the interviews is bilingual since birth, and speaks and reads Sinhalese and English fluently. The second author (KS) understand and speak Sinhalese, while the second and third author (CE) speaks and reads English fluently. The first author being bilingual minimized the language barrier, ensuring that nuances were not missed, thus strengthening credibility of the findings.
Methodological limitations include the majority of informants being Buddhists, thus affecting transferability beyond Sri Lanka [29]. During the analysis all three authors read through the transcribed interviews, and the two (KS and CE) who were unaware of the informants’ religious affiliation could not find any discrepancies in the theme or categories that emerged in any of the interviews indicating religious affiliation. The sample does not include unmarried women without children who have worked throughout their working life period. But as significant others do not necessarily need to be spouses or biological children this is not likely to influence transferability of the results of this study.