Journal of South Asian Federation of Menopause Societies
Volume 7 | Issue 1 | Year 2019

Perception and Awareness of Menopause among Premenopausal Women of Different Socioeconomic Backgrounds

Aisha K Jadoon1, Fasiha Sohail2, Sumera N Qabulio3, Arzu Jadoon4

1,4Department of ICU, Ziauddin University Hospital, Karachi, Pakistan
2,3Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan

Corresponding Author: Aisha K Jadoon, Department of ICU, Ziauddin University Hospital, Karachi, Pakistan, Phone: +92 3432287279, e-mail: aishajadoon@hotmail.com

How to cite this article Jadoon AK, Sohail F, Qabulio SN, et al. Perception and Awareness of Menopause among Premenopausal Women of Different Socioeconomic Backgrounds. J South Asian Feder Menopause Soc 2019;7(1):8–13.

Source of support: Nil

Conflict of interest: None


Objective: To assess the knowledge of premenopausal women belonging to different socioeconomic backgrounds, about symptoms, treatment, myths, and causes of early or late onset of menopause.

Materials and methods: The cross-sectional study was conducted at the Ziauddin University hospital over a period of 8 months. A sample size of 300 was taken. Socioeconomic status was determined by inquiring about income per capita. Knowledge and perception of the premenopausal women were assessed. Data were entered and analyzed using version 20 of SPSS.

Results: The upper class seemed to be highly aware of the common menopausal symptoms. Young females from the lower class had least knowledge about menopause, followed by middle class. 55% of women considered menopause to be a natural aging process rest believed that it is a clinical condition. The majority, with a negative perspective, belonged to lower socioeconomic class.

Conclusion: About a quarter of Pakistanis are living below the poverty line, and since the study suggests that women from this stratum have poor knowledge about menopause, there is a great need for spreading awareness to this class. This study would help improve the quality of life of women belonging to the lower class and would eventually decrease morbidity and mortality due to the consequences of menopause. There is limited research in Pakistan about the knowledge of women regarding menopause, and the focus is diverted more towards evaluating the experience of menopause rather than perception. Adverse socioeconomic conditions are likely to leave deep imprints on psychological well-being of an individual. Hence it can be a major risk factor for the difference in opinion and perception as well as knowledge.

Keywords: Cross-sectional study, Menopause, Myths, Perception, Premenopausal, Socioeconomic status.


Menopause is an inevitable psychological as well as biological event in the reproductive life of every woman. It is cessation of menstrual cycles and periods for 12 consecutive months. The reason is depletion of ovarian function either naturally, or iatrogenic due to bilateral removal of ovaries or ovarian exposure to chemicals and radiation.1 Menopause is linked to a series of problems that arise from ovarian hormones’ deficiency, especially estrogen and progesterone. Menstrual cycle ceases gradually after transition of ovarian function through multiple stages: premenopause, perimenopause, and postmenopause.2

Average age of menopausal women in Pakistan is 49.3 years.3 The age at which menopause occurs is between 45 years and 55 years for women worldwide.4 Mean age is 50 years and 9 months globally.1 In terms of pattern and age, menopause itself varies all around the world; this is seconded by various studies.5 Pakistan is the world’s fifth-most-populous country with a population of 210 million. It has a growth rate of 2.40. The population of Pakistan represents 2.56 percent of the world’s total population6 and is expected to reach 236 million by 2020. 16 million (7.1%) people will be aged more than 60 years, and hence it will have a very large number of menopausal women.7 A few population-based studies have shown a high prevalence of menopausal symptoms between 40% and 70%,8 whereas Asian surveys range between 10% and 50%.9 Turkey reported a prevalence of 35–90%.10 Women’s knowledge, perception, and experience about menopausal symptoms are influenced by many biological, psychological, social, and cultural factors.11

Socioeconomic status in Pakistan is determined by dividing the total population into three classes based on the income of an individual. People who earn Rs 3,000–19,000 per month belong to the lower class, Rs 20,000–1,00,000 belong to the middle class whereas those earning above this fall in the upper-class category.12 Approximately 55 million (24.3%) Pakistanis are living below the poverty line.13,14 According to the Global Wealth Report in 2015, Pakistan has the 18th largest “middle class” in the world.15 54 million (38%) people belong to the middle class, and 3.7 million (2%) people make the upper social class of Pakistan.16

Lower social class comprises women who lack basic necessities, are least educated, confined to kitchen work, and exposed to physical and mental stress. Middle-class women have least to good exposure to medical knowledge. The upper class comprises highly educated and socially aware women. A lot of research has been done worldwide and in Pakistan for the assessment of menopausal knowledge among women of different age groups, ethnic backgrounds, educational levels, etc., but to the best of authors’ knowledge no one has regarded socioeconomic status. It can be a factor for a difference in opinion and perception regarding menopause, and that is what this study suggests.



The study was conducted at two campuses of Ziauddin University hospital, one situated at Clifton and the other at Keamari. Both provide tertiary care. Clifton is one of the posh areas of Karachi and Ziauddin Hospital there, which attracts the elite, upper, and upper-middle class. Keamari residents mostly belong to lower and lower-middle-class, therefore Ziauddin Hospital Keamari campus, caters to these socioeconomic strata.

Study Design

Prospective descriptive cross-sectional study.

Sample Size

300 females were included in the study by random selection that fulfilled the inclusion criteria.

Time Period

September 2017 to April 2018.

Inclusion Criteria

  • Premenopausal women (30–40 years of age) were interviewed
  • Equal number of women, i.e., 100 each from the lower, middle and upper class were included

Exclusion Criteria

  • Early menopausal women
  • Who had never heard about menopause
  • Who had undergone any ovarian or uterine surgeries


Questionnaires were filled by authors after informed consent from participants. Privacy was maintained throughout the interview. Details of participant’s sociodemographic characteristics were recorded.

Socioeconomic status was determined by inquiring about income per month. Knowledge and perception of the participant women were assessed by asking them about the correct option for age of menarche and menopause, definition and causes for its early and late onset, as well as their awareness about certain menopausal symptoms and treatment options.

Statistical Analysis

Data were analyzed using version 20 of SPSS. Chi-square was applied, and p value %3C; 0.05 was taken as significant.


A sample size of 300 women belonging to a range of 30 to 40 years was taken. The mean age was 34.54 ± 3.28. The sample was divided into three socioeconomic classes and analyzed accordingly. 100 women from each class were interviewed.

Table 1: Sociodemographic characteristics
Socioeconomic classMarital status
Lower  613603
Middle  663121
Upper  712333
Total (300)198 (66%)90 (30%)5 (1.6%)7 (2.3%)
Socioeconomic classEducation
Lower562121  2
Middle  9252541
Upper  5  72563
Total (300)70 (23%)53 (18%)71 (24%)106 (35%)
Socioeconomic classEmployment
Total (300)225 (75%)75 (25%)

Sociodemographic characteristics are shown in Table 1.

Of the total participants, 77% (230) had gained primary, secondary, or higher education, whereas 23% (70) were completely uneducated. 19% (44), 39.5% (91) and 41% (95) of the lower, middle and upper class, respectively, were educated. The lower class had the maximum number of uneducated women, i.e., 56 (80%) in contrast to the upper class, which had only 5 (1.6%). Similarly, upper-class women were noticed to be most highly educated of 59% (63/106) when compared to middle 39% (41/106), and the lower class 2% (2/106).

Figure 1 represents different sources of knowledge regarding menopause among young women.

The most popular source of knowledge regarding menopause among participants was relatives 77 (26%). The second was doctors 66 (22%) followed by friends 63 (21%). 11% (32) of the females gained knowledge through television, radio, magazines, or more than one source. 10% (30) knew about it because of attending educational sessions.

Of the total participants, 59 (26%) and 16 (14%) from the lower class, 83 (35%) and 35 (30%) from the middle class, 93 (40%) and 65 (56%) from the upper class knew the correct ages for menarche and menopause. 22 (19%) lower-class women had correct knowledge about the definition of menopause followed by 36 (36%) of the middle class and 57 (50%) of the upper class.

Table 2 demonstrates the knowledge about common symptoms of menopause among women from different socioeconomic classes. It can be seen that 53% of the lower class people, 26% of the middle class, and only 21% of the upper class did not have any knowledge about common symptoms of menopause. 51% (864/1700) women had no idea about menopausal symptoms.

Correct identification of the causes for early- and late-onset menopause is illustrated in Table 3.

Fig. 1: Source of knowledge regarding menopause among participants

Table 2: Knowledge about common symptoms of menopause among women from different socioeconomic classes
YNNo clueYNNo clueYNNo clue
Hot flushes4021396423135143  6
Palpitation5130196621134745  8
Headaches4331267219  94746  7
Body/joint ache503317621820443917
Breast tenderness2650245235138014  6
Sleep disturban CE4434225240  84744  9
Irritabilty5417296430  66034  6
Depression6421155338  93556  9
Loss of libido5431155437  9454312
Vaginal dryness462727493219482824
Dry skin4529265631137121  8
Dry hair422632384616166816
Brittle nails3641233657  71479  7
Total percentage302853373126334121
Table 3: Correct identification of the causes for early- and late-onset menopause
CauseLower classMiddle classUpper classTotal
Early onset menopauseDecreased BMI47 (25%)67 (35%)75 (40%)189
Nulliparity47 (26%)52 (29%)79 (44%)178
Smoking52 (24%)76 (35%)92 (42%)220
Depression75 (32%)72 (31%)88 (37%)235
Poverty77 (33%)72 (31%)84 (36%)233
Radiation/chemicals54 (26%)58 (28%)93 (45%)205
Late onset menopauseIncreased BMI48 (26%)66 (35%)74 (39%)188
Multiparity45 (26%)51 (29%)79 (45%)175
Late onset menarche43 (33%)43 (33%)46 (35%)132

The 367 women (24%; out of 1500) who had no knowledge about menopausal consequences were comprised of 187 (51%) of the lower class, 100 (27%) of the middle and only 80 (22%) of the upper class.

Sixty-three of the total 300 respondents, i.e., 21%, had no idea that menopause can lead to osteoporosis. 93 (31%), 74 (25%), 59 (20%) and 78 (26%) had no clue that it could cause cardiovascular diseases, cancers, weight gain, and diminished vision respectively.

Knowledge about treatment options of menopause among women, varied vastly as shown by the bar graph in Figure 2.

Out of the common myths regarding menopause, considering it to be an indication of old age was more popular between lower (95%) and middle class (88%) whereas upper-class women (47% each) believed in two myths, one that it is an end of sexual life and second that the symptoms only appear after menopause has begun.

Figure 3 shows the percentages of popular myths regarding menopause.

Whereas 166 (55%) of the women considered menopause to be a natural aging process, 134 (45%) believed that it is a clinical condition/disease. 64 women from lower, 54 from middle and only 16 from the upper class considered the latter.


Perception of menopause is not the same around the world; a vast variation exists in women from different ethnic backgrounds.17

Premenopausal women from all socioeconomic strata were interviewed so that an estimation of the number of ignorant female population could be made at an earlier stage. This would also help in identifying the target class that deserves maximum attention for awareness. Results showed that more than two-thirds were married. Majority of uneducated women belonged to the lower class in contrary to which the upper class consisted of the highly educated whereas middle-class females had mostly studied until the 5th grade or maximum 10th standard with a negligible number of illiterate women. This was similar to a study conducted in Hyderabad.18

Fig. 2: Knowledge about treatment options of menopause among women from different socioeconomic classes

Fig. 3: Popular myths regarding menopause

Only a quarter of the women included in the current study was either unemployed or were housewives. 75% were employed. Working and uneducated women suffer more from psychological and somatic symptoms.19 In the authors’ opinion, working women might be more knowledgeable about social and health issues. But arguing about this is beyond the scope of this survey.

Women in this study reported relatives to be the first source of knowledge, followed by doctors, friends, and media. Very few gained knowledge through more than one source. Some from the upper class and middle class knew about menopause because of attending educational sessions. Another study conducted in Karachi also had relatives as the first source.20 But the study by Fouzia et al. suggested that 60% had heard about menopause from a health-care provider.21

Correct answers for the age of menarche and menopause were given by upper-class women followed by the middle and then the lower class. When asked about the definition of menopause majority of the wrong answers were given by the lower class.

There are certain factors that lead to early or delayed onset of menopause. A study conducted in Boston, Massachusetts, proposed that women who suffer economic distress were at a 1.75 times higher risk of perimenopause and 1.2 years earlier menopause as compared to women reporting no lifetime economic distress.22 Another study done at California, USA, suggested that socioeconomic status affects the age at natural menopause onset.23 Early menopause protects against breast cancer, but increases the chances for uterine and ovarian cancer as well as cardiovascular disease.24,25 The common causes of early menopause are smoking, radiation, chemotherapy,25 underweight, low income, less education,26 lack of exercise, nulliparity, breastfeeding, early age of menarche, and occupational or environmental stress. The known causes for late onset of menopause are increased BMI, multiparity, menarche at a later age, strenuous exercises, and specific geographical and racial factors.25 In this study, the upper class seemed to be well aware of all the causes for both early and late onset of menopause followed by the middle and then the lower class. Lower middle class women only identified correctly depression and poverty to be the causal factors.

Social and cultural beliefs influence menopause symptoms, and almost 80% of women suffer from physical and psychological symptoms in the West.27 Various symptoms, especially those mentioned in MRS (menopausal rating scale), were added to the questionnaire to assess the knowledge of women, regarding menopause. According to the literature survey in Pakistan, lethargy, body aches, and backaches were found to be the most common menopausal symptoms.28 In the current study among all the symptoms, most of the women from lower-class identified depression, middle class considered headache, whereas majority of the upper class thought dry skin to be a common symptom of menopause. Altogether the lower class was again the most unaware. Almost half of the women from the entire sample had zero knowledge about the symptoms of menopause.

Western women tend to have better information about consequences of menopause.29 In this study, it was suggested that 75% of females had some clue about the main adverse effects of menopause. Only a quarter were unaware; among this 51% were from the lower class, followed by the middle and upper class. One-fifth had no clue that menopause could lead to weight gain, and a similar fraction (21%) was naive to osteoporosis. A quarter of the total participants gave no response to cancers and vision disturbances, whereas 31% did not know that menopause could increase the risk for cardiovascular diseases. This was quite similar to a survey conducted at Mexico City, which illustrated that 83.8% of women have knowledge about climacteric symptoms and 90% knew about osteoporosis in particular,30 identical results were yielded by Sadia et al.’s31 study about assessment of young women’s knowledge about menopausal symptoms, done in 2013 at Karachi. Contrary to this a survey by Farah et al.32 conducted in 2010 about perception of menopause among elderly women showed that only a small number of women were aware of consequences of menopause and diminished vision was recognized as the most famous implication followed by osteoporosis.

Some of the basic treatment options adopted by women for decreasing the severity of menopausal symptoms are hormone replacement therapy (HRT), herbal remedies, lifestyle changes, calcium-rich diet, dilatation and curettage (D and C) and a traditional Chinese treatment method: acupuncture.33 Many international and national studies suggest that knowledge about HRT is scarce.34 This study showed that knowledge about these treatment options varied class wise. Lower- and middle-class women had heard of popular herbal remedies and stressed upon specific diet plans for relief of menopausal symptoms, but only a few heard about HRT. The upper class was found to be very well aware of HRT. Acupuncture and D and C were least popular solutions among women in the current study. Myths regarding menopause are still prevailing globally.35,36 The current study suggested that most women from the lower and middle class considered menopause to be an indication of old age, and believed that its symptoms appear only when the actual menopause commences. A large proportion among the upper class thought that it would end their sexual life and deemed the process to be worrisome. Although the least as compared to the above myths but a good number believed that symptoms were untreatable. This was identical to the response by most Asian women as majority consider menopause as an expected part of life.37 Keeping in view these findings, it can be said that myths rule all minds regardless of socioeconomic status.

Women in eastern societies view menopause as a natural process and hold a positive attitude.38 More than half of the premenopausal women included in the current study believed the same. Majority having negative thoughts about menopause belonged to the lower class, and most of the upper-class women had an optimistic attitude. Similar findings were by Farah et al.,32 who suggested that 78.5% perceived menopause as a natural process, and Mahajan et al.39 found that 44% of the women are affected in a negative manner during the menopause stage. Similar were the results achieved by a survey done in Punjab.40

In this study, majority of illiterate women belonged to the lower class and with least knowledge about menopause. This suggests that this class direly needs awareness.


The study identifies that doctors are not the first source of knowledge among the premenopausal population; this means physicians should discuss this topic with patients more often as to spread correct knowledge and alleviate negative attitudes and myths. The current study indicates that among the three socioeconomic classes, premenopausal women from the lower class have the least knowledge about menopause, its symptoms and treatment.


Since the life expectancy is rising all over the world, it will make more women live up to the age of menopause. Hence they should have awareness about the health risks menopause can expose them to as well as the prevention. Majority of the women of Pakistan belong to the lower class strata, and hence to decrease the morbidity and mortality caused by menopausal effects, this class should be familiarized with the inevitable process of menopause.


1. Inayat K, Danish N, et al. Symptoms of menopause in peri and postmenopausal Women and their attitude towards them. J Ayub Med Coll Abbottabad 2017;29(3):477–480.

2. Soules MR, Sherman S, et al. Executive summary: stages of reproductive aging workshop (STRAW) Park City, Utah, July 2001. Menopause 2001;8:402–407.

3. Nisar N, Sikandar R, et al. Menopausal symptoms: prevalence, severity and correlation with sociodemographic and reproductive characteristics. A cross sectional community based survey from rural Sindh Pakistan. J Pak Med Assoc 2015 Apr;65(4):409–413.

4. Shakila P, Sridharan P, et al. An Assessment of Women’s Awareness and Symptoms in Menopause. Journal of Business and Economic Policy December 2014;1(No. 2):2375.

5. Qazi AR. Age, Pattern of menopause, climacteric symptoms and associated problem among urban population of Hyderabad Pakistan. J Coll Physicians Surg Pak 2006;16:700–703.

6. Pakistan Bureau of Statistics, 2018, January 03, http://www.pbs.gov.pk/population-tables.

7. Population reference bureau 2010. World population data sheet[internet]2010 [cited 2010] available from http://www.prb.org/datafinder/geography/summary.region=146andregiontype=2.

8. Avis NE, Crawford SL, et al. Psychosocial, behavioral, and health factors related to menopausesymptomatology. Womens Health 1997;3:103–120.

9. Boulet MJ, Oddens BJ, et al. Climacteric and menopause in seven South-east Asian countries. Maturitas 1994 Oct;19(3):157–176. DOI: 10.1016/0378-5122(94)90068-X.

10. Uncu Y, Alper Z, et al. The perception of menopause and hormone therapy among women in Turkey. Climacteric 2007;10:63–71. DOI: 10.1080/13697130601037324.

11. Dillaway H, Byrnes M, et al. Talking “Among Us”: How women from different Racial-Ethnic Groups Define and Discuss Menopause. Health Care Women Int 2008;29:766–781. DOI: 10.1080/07399330802179247.

12. Subohi A. 2006, November 20, Defining income groups. DAWN, Retrieved from http://www.dawn.com.

13. Rana Shahbaz. 2018, April 27, Pakistan posts 5.8% growth rate. The Express Tribune, https://tribune.com.pk/story/1696282/2.

14. Human Development Report 2016, UNDP Pakistan; Human Development For Everyone http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/PAK.pdf.

15. Alam K. mohsin alam 2015, October 16, Global Wealth Report 2015, The Express Tribune %3E; Business. Retrieved from https://tribune.com.pk/story/973649/.

16. Siddiqui S. 2017, May 2. The Express Tribune > Business Pakistan’s middle class continues to grow at rapid pace. https://tribune.com.pk/story/1398602/.

17. Borland S. Loosing 10lbs ‘can reduce menopause symptoms’ including hot flushes and night sweats. the Daily MailPublished: 01:16 BST, 12 July 2012 | Updated: 01:16 BST, 12 July 2012.

18. Nusrat N, Nishat Z, et al. Knowledge, attitude and experience of menopause. J Ayub Med Coll Abbottabad 2008;20:56–59.

19. Kakkar V, Kaur D, et al. Assessment of the variation in menopausal symptoms with age, education and working/non-working status in north-Indian sub population using menopause rating scale (MRS). Maturitas 2007 Jul 20;57(3):306–314. DOI: 10.1016/j.maturitas.2007.02.026.

20. Baig LA, Karim SA. Age at menopause, and knowledge of and attitudes to menopause, of women in Karachi, Pakistan. J Br Menopause Soc 2006;12(issue 2):71–74. DOI: 10.1258/136218006777525721.

21. Memon FR, Jonker L, et al. Knowledge, attitudes and perceptions towards menopause among highly educated Asian women in their midlife. Post Reprod Health 2014;20(issue 4):138–142. DOI: 10.1177/2053369114557510.

22. Gold EB. The Timing of the Age at Which Natural Menopause Occurs. Obstet Gynecol Clin North Am 2011 Sep;38(3):425–440. DOI: 10.1016/j.ogc.2011.05.002.

23. Wise LA, Krieger N, et al. Lifetime socioeconomic position in relation to onset of perimenopause. J Epidemiol Community Health 2002 Nov;56(11):851–860. DOI: 10.1136/jech.56.11.851.

24. Kritz-Silverstein D, Barrett-Cannor E. Early menopause, number of reproductive years, and bone mineral density in postmenopausal women. Am J Public Health 1993;83:983–988. DOI: 10.2105/AJPH.83.7.983.

25. Kelsey JL, Gammon MD, et al. Reproductive factors and breast cancer. Epidemiol Rev 1993;15:36–47. DOI: 10.1093/oxfordjournals.epirev.a036115.

26. Choe S, Kim Y, et al. Factors for premature or early menopause: a comparative study between United States and South Korean women. Obstet Gynecol Clin North Am 2011 Sep;38(3):425–440. DOI: 10.1016/j.ogc.2011.05.002.

27. McLennan AH. Current management of the menopause. Aust Family Physician 1988;17:158–169.

28. Waheed K, Khanum A, et al. Quality of Life after Menopause in Pakistani Women. Gynecol Obstet (Sunnyvale) 2016;6:367.

29. Hsien AP, Wu HM, et al. Perception of menopause among women in Taiwan. Maturitas 2002;41(4):269–274. DOI: 10.1016/S0378-5122(01)00279-1.

30. Velasco MV, Navarrete HE, et al. Experience and knowledge about climacteric and menopause in women in Mexico City. Ged Med Mex 2000;136(6):555–564.

31. Mujahid S, Siddiqui AA, et al. Awareness of Menopausal Symptoms among Young Pakistani Women of Different Educational Backgrounds. J South Asian Feder Menopause Soc 2013;1(1):18–20. DOI: 10.5005/jp-journals-10032-1004.

32. Karim F, Ghazi A, et al. Women’s Perception Towards Menopause. Journal of Surgery Pakistan (International) 2013;18(3):143–147.

33. Lam PM. Climacteric symptoms and knowledge about hormone replacement therapy among Hong Kong Chinese women aged 40–60 years. Maturitas 2003;45:99–107. DOI: 10.1016/S0378-5122(03)00090-2.

34. Khokhar S. Knowledge, Attitude and Experience of Menopause. Pak J Med Res 2013;52(No. 2):42–46.

35. Matthews KA. Myths and realities of the menopause. Psychosom Med 1992;54(1):1–9. DOI: 10.1097/00006842-199201000-00001.

36. Wambua LT. African perceptions and myths about menopause. East Afr Med J 1997;74:645–656.

37. Punyahotra S, Dennerstein L, et al. Menopausal experiences of Thai women. Part 1: Symptoms and their correlates. Maturitas 1997;26:1–7. DOI: 10.1016/S0378-5122(96)01058-4.

38. Aaron R, Muliyet J, et al. Medico-social dimension of menopause: a cross national study from rural south India. Nalt Med J India 2002;15:14–17.

39. Mahajan N, Aggarwal M, et al. Health issues of menopausal women in North India. Journal of mid-life health 2012;3:84–87. DOI: 10.4103/0976-7800.104467.

40. Yahya S, Rehan N. Perceptions of menopause among rural women of Lahore. Journal of the College of Physicians and Surgeons–Pakistan: JCPSP 01 May 2003;13(5):252–254.

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