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Original Article
Healthy Life Style Behaviors and Quality of Life at Menopause
Handan Ozcan, PhD
Assistant Professor, Department of Midwifery, Faculty of Health Sciences, University of Health Sciences,
Istanbul, Turkey
Correspondence:
Handan Ozcan, PhD, Assistant Professor, Department of Midwifery, Faculty of Health
Sciences, University of Health Sciences, Istanbul, Turkey e-mail: hndnozcn@hotmail.com
Abstract
Background: Menopause is a natural period of change in which a woman's reproductive ability stops. In studies
conducted, it has been shown that the symptoms seen in women decrease with the healthy life style behaviors,
and there are not enough studies on this topic.
Objective: The aim of the study was to evaluate healthy life style behaviors and quality of life of women at
menopause period.
Methods: The study is a descriptive and cross-sectional type of research. The universe of the study consisted of
women who applied to a State Hospital at a particular time and who were at the age of 45-65 years and at
menopause period, and the sample of the study consisted of targeted 500 women who accepted to participate in
the study voluntarily. The necessary institutional and ethics committee permissions were obtained. “Participant
Information Form”, “Healthy Life Style Behavior Scale (HLBS)” and “Menopause-Specific Quality of Life
Questionnaire (MENQOL)” were used in the collection of the data.
Results: In the study, the average age of women was 56.49±6.30 and the average age of menopause was
47.70±4.70. In the study, 65.1% of the women did not receive any medical help at menopause period and 28.6%
of them exercised as an alternative treatment method.
Conclusion: In the study, there was a negative relationship found between total scores of HLBS and total scores
of MENQOL. It was determined that complaints decreased with the increase of HLBS in women who were at
menopause period.
Key Words: Menopause, healthy life style behaviors, quality of life
Introduction
Menopause is a natural period of change in
which a woman's reproductive ability stops, and
that appears usually at the end of forties and at
the beginning of fifties. As a result of decrease in
fertility, it is the outcome of biological aging that
occurs suddenly or not suddenly in a few years
(Bener, Saleh, Bekir, & Bhugra, 2016; Gerber,
Bener, Al-Ali, Hammoudeh, Liu, & Verjee,
2015).
The average menopause age worldwide is 51,
ranging from 45 to 55. Menopause age is earlier
in developing countries than in developed
countries. Menopause age in developed countries
is between 49.3 and 51.4 while in developing
countries, it is between 43.5 and 49.4. For
example, menopause age is 50-51 in Jordan, 47
in Turkey and 48 in Egypt (Gharaibeh, Al-
Obeisat & Hattab, 2010; Simon, Kaunitz, Kroll,
Graham, Bernick, & Mirkin, 2018).
The most characteristic complaints of
postmenopause include vasomotor symptoms
such as hot flushes, night sweating, urogenital
atrophy, osteopenia, osteoporosis, psychiatric
disorders, sexual dysfunctions, skin lesions,
cardiovascular diseases, cancer, metabolic
disorders and obesity. All of these complaints
affect quality of life of women negatively. The
most common metabolic disorders in menopause
are dyslipidemia, impaired glucose tolerance,
insulin resistance, hyperinsulinemia and type 2
diabetes (Lobo, et al., 2014).
In the decision made in 2006 by The Scientific
Advisory Committee of The Royal College of
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Obstetricians and Gynaecologists, non-drug
applications are recommended for the decrease
of menopause complaints (RCOG, 2006).
Menopausal symptoms affect quality of life and
duration of life of women negatively. For this
reason, preventive measures should be
considered before pharmacological treatment in
women going through menopause.
Therefore, it is very important to make
individuals gain healthy life style behaviors.
These behaviors are: Medium level physical
activity (at least three times a week and at least
30 minutes of moderate exercise); healthy diet,
for example, daily salt consumption less than 300
mg (according to British Hypertension Society
guidelines), consumption of 1 g calcium per day,
providing 800 IU vitamin D intake, reduction of
carbohydrate and fat consumption, increase in
consumption of fruits, vegetables and seafood; to
quit smoking and alcohol; to ensure that these
behaviors are remained.
Lowering body mass index (BMI) below 25
kg/m2 is aimed with these behaviors and body
weight is maintained at normal level (Elsan,
2018; Lobo et al., 2014; Stachowiak, Pertynski &
Pertynska-Marczewska, 2015).
Also, healthy lifestyle behaviors affect the
severity of menopausal complaints. In relevant
studies, it has been shown that healthy lifestyle
behaviors have an important effect in reducing
menopausal complaints. The habit of having a
healthy diet and regular exercising, the success in
stress management, the availability of
interpersonal support systems, self-esteem, self-
fulfillment and general awareness of health
responsibility ensure woman at this period to
experience it with less complaints and more
comfort (Batista, et al., 2018; Kocak, 2017).
Symptoms seen in menopausal periods in which
women spend most of their life time increase the
complaints of women and decrease their quality
of life. In studies conducted, it has been shown
that the symptoms seen in women decrease with
the healthy life style behaviors, and there are not
enough studies on this topic. Generally, studies
conducted are related to alternative treatment
methods and they result in an extra cost.
In this study planned, healthy life style behaviors
and quality of life of women at menopause
period were assessed. Whether the healthy life
style behaviors including physical activity,
nutrition, spiritual development, health
responsibility, interpersonal relations and stress
management affect the quality of life of women
at menopause period, and the relationship
between them will be determined.
Methods
Type of Research, Universe of Research and
Sample Selection: This is a descriptive and
cross-sectional type of research. Women who
applied to a State Hospital in August, September
and October 2017 and who were in the age range
of 45-65 years and at postmenopausal period
constituted the target population of the study.
The sample size was calculated to be 500
women.
Application Permit of Research: Institutional
permission was obtained from Gumushane
General Secretariat and the ethics committee
permission was taken from the Scientific Ethics
Committee of Gumushane University (Approval
Number= 95674917-044-E.9674).
Collection of Research Data and Data
Collection Tools: A pilot study was conducted
with 15 women who answered the
questionnaires. Thereafter any of their comments
were used to improve the questions so that they
would be better understood. Before each form
was filled by the participants, the aim of the
study was explained to them. Verbal or written
consent were obtained from women who
accepted voluntarily to participate in the study.
The data was collected by face to face interviews
with the women included in the study, using data
collection tools. The answers were recorded by
reading each question one by one to each person,
in a loud and clear way. The questionnaire form
which consisted of three parts and prepared by
the researcher as a result of the evaluation of
relevant literature was applied to the women who
met the criteria for inclusion in the study. The
first part of the questionnaire form was a
question form questioning participants' socio-
demographic, obstetric and gynecological
characteristics and their chronic disease history,
information on menopause period and general
health behaviors. The second part was “Healthy
Lifestyle Behavior Scale (HLBS)” and the third
part was “Menopause-Specific Quality of Life
Questionnaire (MENQOL)”.
Healthy Lifestyle Behaviors Scale (HLBS)
The scale was developed by Walker et al. in
1987 and re-examined in 1996. Bahar et al.
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adapted the scale into Turkish in 2008 (Bahar,
Beser, Gordes, Ersin, & Kisal, 2008; Walker,
Sechrist & Pender, 1987). The scale measures the
health behaviors developed relatively with the
healthy life style of the individual. The scale has
a total of 52 items and 6 subgroups (self-
realization, health responsibility, exercise,
nutrition, interpersonal support and stress
management). The total score of the scale gives
the score of healthy lifestyle behaviors scale
(HLB). All items of the scale are scored
positively and no items are scored reversely. The
rating is a 4-point likert type (never (1),
sometimes (2), often (3), regularly (4)). For the
whole scale, the lowest score is 52 and the
highest score is 208. The higher the score taken
from the scale, the better the HLBS
Menopause-Specific Quality of Life
Questionnaire (MENQOL)
The scale was developed by John R. Hilditch,
Jacqueline Lewis et al. in 1996 to create a quality
of life scale that is specific to menopausal health
status with psychometric properties based on
women's experience, was adapted to Turkish
society by Kharbouch and Şahin in 2005, and
validity and reliability of the questionnaire were
determined (Kharbouch & Şahin 2007). Each
subdomain score of MENQOL is ranged from 1
to 8. 1 point indicates that there are no problems
faced about that topic. 2 points indicate that this
topic exists, it is being experienced but it is not
annoying at all. Points between 3-8 indicate the
severity of the problem and the increasing levels.
The scale consists of four symptoms: vasomotor,
psycho-social, physical and sexual.
Results
The average age of women who participated in
the study was 56.49±6.30. 43.2% of the women
and 35.9% of their spouses were primary school
graduates, 73.2% were housewives and 56.4% of
their spouses were retired. 74% of the
participants were married and 50.4% stated that
their expenses were equal to their income.
Of the women, 16.4% (n=82) were smokers and
0.8% (n=4) were consuming alcohol. The
average body mass index (BMI) of the women
was 28.90±4.78. The average menopause age of
women who participated in the study was
47.70±4.70. The information status of
menopause period of women is given in table 1.
A 65.1% of the women did not receive any
medical help during menopause period, only
39.5% received information from healthcare
personnel, 31.6% received herbal treatment for
their complaints and 28.6% exercised as an
alternative treatment during menopause period.
The average HLBS and MENQOL scores of
women who participated in the study are given in
Table 2.
According to the comparison of HLB scale
scores among women, the lowest score was
found in exercise subscale, 13,87±5.07 (min=8,
max=32), the highest score was found in
interpersonal support subscale, 26.31±5.16
(min=9, max=36), and the total score average of
HLB was 132.31±21.42 (min=52, max=228).
According to the comparison of MENQOL
scores among women, the lowest score was
found in sexual symptoms subscale, 8.77±5.23
(min=0, max=24), the highest score was found in
physical symptoms subscale, 47.09±18.38
(min=0, max=128), and the total score average of
MENQOL was 83.49±29.10 (min=0, max=228).
No significant difference was found in the
advanced analysis test (ANOVA) performed
between the delivery method and place of
women, and HLBS and MENQOL.
Significant differences were found as a result of
the comparison of the educational status scale
scores of women at menopause period. As the
education level of women increased, HLBS
scores (F=4.346, p=.001) increased. As the
education level of women increased, physical
symptoms subscale and total scale scores of
MENQOL decreased (F=3.538, p=.004).
In addition, as the income status of women
decreased menopause-based complaints
increased (F=8.869, p=.000). Also, psychosocial
and physical symptoms which were among the
sub-groups of MENQOL increased. The
relationship between HLBS and MENQOL
scores of the participants is shown in Table 3.
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Table 1. The information status of menopausal transition of women
Status of receiving medical help at menopause period n %
Yes
No
Total
174
325
499
34.9
65.1
100.0
Sources used for the information at menopause period n %
TV (Media)
People around
Health personnel
Total
67
232
195
494
13.6
47.0
39.5
100.0
Status of using herbal treatment to eliminate complaints
at menopause period
n %
Yes
No
Total
156
339
495
31.6
68.4
100.0
Status of beginning any alternative treatment at
menopause period
n %
Yoga
Massage
Exercise
Acupuncture
Other
No
Total
2
48
143
3
187
117
500
0.4
9.6
28.6
0.6
37.4
23.4
100.0
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Table 2. The average Healthy Life Style Behavior Scale and Menopause-Specific Quality
of Life Questionnaire scores of women
HLBS n ort±ss min max
Health Responsibility
Exercise
Nutrition
Self-Realization,
Interpersonal Support
Stress Management
Total
498
498
498
498
498
498
498
24.07±5.65
13,87±5.07
22.77±4.55
25.56±4.69
26.31±5.16
20.09±4,18
132.31±21.42
9
7
11
10
12
9
67
55
48
44
38
40
36
222
MENQOL
Vasomotor
Psychosocial
Physical
Sexual
Total symptoms
493
497
498
481
498
11.21±4.75
17.12±9.43
47.09±18.38
8.77±5.23
83.49±29.10
0
0
0
0
0
18
48
97
18
156
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Table 3. The relationship of Healthy Life Style Behavior Scale and Menopause-Specific Quality
of Life Questionnaire scores
HLBS
sub-dimension
Vasomotor
Psychosocial
Physical
Sexual
Total
Health
Responsibility
r
p
.029
.522
-.072
.108
-.099*
.027
.054
.237
-.062
.170
Exercise
r
p
.028
.532
-.089*
.048
-.131**
.003
-.074
.108
-.123*
.006
Nutrition
r
p
.
109*
.016
-.014
.753
-.022
.621
.089
.050
.013
.775
Self-Realization
r
p
-.018
.685
-234**
.000
-.090*
.044
-.084
.067
-.155**
.001
Interpersonal
Support
r
p
.013
.774
-.205**
.000
-.050
.263
-.084
.065
-.109*
.015
Stress Management
r
p
.018
.697
-.135**
.003
-.056
.212
-.024
.608
-.073
.104
Total
r
p
.044
.325
-.164**
.000
-.095*
.034
-.014
.755
-.107*
.017
r= spearman correlation analysis
As a result of the evaluation of the
relationship between HLBS and MENQOL
scores: A negative relationship was found
between HLBS health responsibility sub-
dimension and MENQOL physical
symptoms sub-dimension. It was determined
that as the health responsibility increased in
women, especially physical complaints
related to menopause period decreased.
A negative relationship was found between
HLBS physical activity subscale, and
MENQOL psychosocial symptoms, physical
symptoms subscales and total scores. It was
determined that as physical activity increased
in women, physical complaints and
psychological problems related to
menopause period decreased.
There was a positive relationship between
HLBS nutrition sub-dimension and
MENQOL vasomotor symptoms sub-
dimension. It was determined that the
nutritional status of women at menopause
period affected vasomotor symptoms.
There was a negative relationship found
between HLBS self-realization sub-
dimension, and MENQOL physical
symptoms sub-dimension and total scores.
With the increase of spiritual development,
physical complaints decreased in women at
menopause period.
A negative relationship was found between
HLBS interpersonal relations subscale and
MENQOL total scores. It was determined
that menopausal symptoms decreased with
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the increase in interpersonal relations among
women.
In the study, a negative relationship was
found between the total scores of HLBS and
the total scores of MENQOL. Women at
menopause period were found to have
decreased complaints as HLBS increased.
Discussion
World Health Organization (WHO) defines
menopause as the "permanent termination of
menstruation as a result of the loss of ovarian
activity". It is associated with the decrease in
estrogen secretion that occurs
physiologically due to loss of follicular
functions. The average menopause age
worldwide is 51, ranging from 45 to 55
(Gharaibeh, Al-Obeisat & Hattab, 2010).
The average age of women in the study was
56.49±6.30. 43.2% of the women and 35.9%
of their spouses were primary school
graduates, 73.2% were housewives and
56.4% of their spouses were retired. 74% of
the participants were married and 50.4%
stated that their expenses were equal to their
income. Educational status of women was
lower than of their spouses. Our findings are
similar with the study conducted by Tunc
(Tunc, 2014). The higher education level, the
fact that women have more knowledge about
health-related issues and healthy life styles
can lead them to be less affected by
menopausal symptoms. In the study
conducted by Koyuncu, severe somatic and
urogenital symptoms were less common
among menopausal women who had
secondary and higher education level
(Koyuncu, 2015).
The average number of pregnancies of
women was 4.66±2.63, the average number
of births was 3.78±2.04, the average number
abort was 1.58±1.09, and the average
number of abortion was 1.54±0.88. 79.7% of
the participants had vaginal delivery, 38.2%
gave birth at home and 12.8% had a
gynecological operation. The fact that the
province where the study was conducted has
a traditional cultural structure, the fact that
the age range of women who participated in
the study was advanced, and the fact that the
education levels of women were low are
considered as the reasons for high rate of
delivery at home.
65.1% of the women did not receive any
medical help during menopause period, only
39.5% received information from healthcare
personnel, 31.6% received herbal treatment
for their complaints and 28.6% exercised as
an alternative treatment during menopause
period. In particular, the findings indicate
that women spend menopause period which
is the one third of their lives, without having
knowledge about the period. In the study
conducted by Tunc, the women's status of
receiving information about menopause was
evaluated and it was found that 58.7% of
them received information, 77.2% received
this information from a physician and 14.1%
received it from a midwife (Tunc, 2014).
When HLB scale scores were compared
among women, it was determined that the
best health behavior was interpersonal
relations, and the least behavior was physical
activity.
When MENQOL scores were compared
among women, it was determined that the
least common complaint was about sexual
symptoms and the most common complaint
was about physical symptoms.
Significant differences were determined
between income and education status of
women at menopause, and HLBS and
MENQOL scores. It was found that as the
education level and income status of women
increased, HBLS increased, the menopause-
specific complaints reduced and the quality
of life of women decreased.
Women who have low family income status
are considered to less benefit from healthcare
services than women who have high income
status. In some studies conducted, symptoms
of menopause are reported to be more
frequently seen in women who have low
family income status (Im, Ko & Chee 2014;
Karacam & Seker 2007). Also in a study
conducted, it was stated that the frequency of
menopausal symptoms was lower among
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women who had low family income. It was
found that the presence of severe somatic
symptoms was lower among women who
had good family income and it was reported
that this difference was abolished, according
to the result of logistic regression analysis
(Kaulagekar, 2011).
As a result of the evaluation of the
relationship between HLBS and MENQOL
scores, it was determined that the physical
symptoms decreased as the health
responsibility of women at menopause
increased. Physical symptoms and
psychological symptoms were found to
decrease with the increase of physical
activity. It was determined that the
nutritional status and vasomotor symptoms
of menopausal women were affected, that
physical symptoms decreased with the
increase of self-realization, and also that the
symptoms of menopause reduced with the
increase of interpersonal relations.
In the study, a negative relationship was
found between the total scores HLBS and the
total scores of MENQOL. It was determined
that complaints and thus quality of life
decreased with the increase of HLBS in
women at menopause.
Conclusion
Reduction of the complaints of women at
menopause period to minimum level with
healthy life style behaviors and thus the
increase of the quality of life of women are
important factors. In menopausal period, it is
very important for women to know what to
do against physical and psychological
problems experienced, to use effective
coping mechanisms, to be supported to
continue their healthy life and to gain healthy
life style behaviors.
Main points in coping with menopause:
1. To provide necessary trainings on
menopause to women and their families,
2. To discuss aspects related to
menopause,
3. To overview healthy life style
behaviors such as diet, exercise, smoking
and to support individuals to gain positive
health behaviors,
4. To overview methods of coping with
stress and to encourage the development of
them,
5. To discuss personal, health and social
issues affecting middle-aged women,
6. To ensure that appropriate counseling
is carried out individually or in groups
7. To increase the quality of life of
women at menopause period, are needed.
Acknowledgements: The author thank the
patients included in the research.
Funding: This work was supported by
Scientific Research Projects Coordination
Unit of Gumushane University (Project
number 17.A0110.02.01).
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