| Abstract|| |
Context : Menopause is one area that has been shrouded in myths and taboos and the way women perceive menopause depends largely on the social belief about menopause in their society. Objective : The aims of this study are to assess how women perceived the physical changes during menopause, what the social as well as the individual adjustment practice to menopausal changes might be. Materials and Methods : Qualitative focal group study among women aged 40 years and above where eight to ten volunteers formed a group. Six sessions were held for different focal group, each lasting 1-2 h. A tape recorder and a notepad were used to record the discussions. Opinions of the women were sought on socio-cultural differences in the perception of aging, perception of menstruation, perceived causes and consequences of menopause, sexual intercourse after menopause, social support networks for menopausal women, and types of care and treatment for women in menopause. Results: The participants in the FGDs used various phrases to describe menopause in local term; while some of the participants attributed disease to be a cause of menopause, others believed that it be could be caused by witchcraft or sorcery. However, younger and old women whose menstrual flow stops prematurely seek assistance, often from traditional or spiritual healers. Conclusion: This study reveals the poor menopausal knowledge among the study group with more than half of the respondents having negative attitude towards menopause in addition to mixed feelings about religious obligation and cohabitation.
Keywords: Aging, focus group discussions, menopause, menstruation, myths
|How to cite this article:|
Saka MJ, Saidu R, Jimoh A, Akande T, Olatinwo AW. Behavioral pattern of menopausal Nigeria women. Ann Trop Med Public Health 2012;5:74-9
|How to cite this URL:|
Saka MJ, Saidu R, Jimoh A, Akande T, Olatinwo AW. Behavioral pattern of menopausal Nigeria women. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Feb 20];5:74-9. Available from: http://www.atmph.org/text.asp?2012/5/2/74/95953
| Introduction|| |
Women in midlife face a variety of challenges. These challenges include the physiological and psychological events of menopause. Many women go through these years without any difficulty, but for some, it is a time of real stress, which is often made difficult because of ignorance and lack of knowledge. 
Most societies have localized sets of social beliefs about different aspects of life, including menopause. In some cultural settings, it is believed that women become wiser and thereafter can rise in social status and even assume leadership positions.  In others, however, menopause is associated with losses, poor health and low self-esteem. 
The experience of menopause is one area that has been shrouded in myths and taboos. Women are led to expect an inevitable and swift decline in their physical, psychological, and intellectual well being which means becoming unhealthy, emotionally bereft and mentally dull.  A survey reports that separating myth from reality may be difficult for women who do not usually seek medical advice about the menopause on a routine basis. 
Presently, in Nigeria, women have higher life expectancy than men. This translates to mean that women in their postmenopausal period make up a majority of the elderly population. Little is known about issues relating to the menopause in Nigeria and study area in particular. There is virtually no data on age distribution of the menopause, the knowledge about it, and information on attitude and adjustment practices of individual menopausal women.
The aims of this study are to assess how women perceived the physical changes during menopause and what the social as well as the individual reaction to them might be. It also aims to verify social definition of menopause and locality-specific perceptions of the causes of menopausal symptoms and to discover any local treatment for menopausal symptoms.
| Materials and Methods|| |
The study followed a qualitative approach towards evaluating the opinions of a group of women on the subject of menopause. The subjects used for the study consisted of menopausal women aged 40 years and above who had stopped menstruating for 12 consecutive months, living in Ilorin metropolis.
Multistage sampling technique was used in selecting both subjects and controls for the study. The multistage sampling technique was carried out first by the selection of six wards, 50% out of 12 wards, in the metropolis and three streets of out of six streets in each ward are selected by simple random sampling techniques.
Houses in each street were then selected using simple random technique by balloting method.
All the women in each of the sampled houses that met the inclusion criteria for selection were interviewed and sought for their concert to participate in Focus Group Discussion (FGD). Cases where it happened that the subjects needed in the houses for the study were not available when the survey team made its visit, or that the house was empty when visited, arrangements were made to make repeated visits up to three times until subjects were at home. Eight to ten volunteers' subjects of homogenous socio-economic background to allow for active participation and response formed a focus group in the six sessions conducted for different focal groups.
Inclusion criteria into the study were women aged 40 years and above who had stopped menstruating for 12 consecutive months. Exclusion criteria were women aged less than 40 years, women of age 40 years and above who were frail, or bedridden, and women of age greater than 40 years but still menstruating.
A tape recorder and a notepad were used to ensure that every aspect of the sessions was clearly recorded for ease of reference. A camera was also available to take a group photograph at the end of each session. At the beginning of each session the researcher was introduced and the purpose of the study was explained. The benefit of such program to the individual involved and the community at large was highlighted. Convenient sitting environment and relaxed atmosphere was provided, and the sitting arrangement was in circle to permit eye-to-eye contact. The researcher moderated the discussion while the research assistant took notes of the proceedings and a cassette recorder was placed to record the discussions. Each session lasted for 1-2 h. The moderator (researcher) presented a summary of the discussion at the end of each session.
Processing and analysis of data from qualitative methods
After each FGD session, a debrief (meeting) was held between the moderator and recorder to examine the focus group activities and results. A longer debriefing was held at the end of the final session. The tape recordings were transcribed and reconciled with the notes taken. The full recording was then edited to remove responses/sessions that were poorly transcribed. Finally, similar responses in the FGDS were group-coded, analyzed, and presented.
| Results|| |
All the women who met inclusion criteria contacted agreed to participate in FGD. The mean age of the respondents was 57.2±1.2 years. Majority (72.5%) of the respondents were of Islamic faith, were of Yoruba ethnic group (80.9%), and were married (65.7%). Over half of the respondents (52.8%) had some form of formal education and 37.1% were traders. [Table 1] shows the socio-demographic characteristics of the respondents.
Opinions about socio-cultural differences in the perception of aging
"Old age is a time when people are given respect, whether male or female. An important role we performed in the families and communities is to settle disputes, at the same time to set a good example for young people as well as to provide wise counsel" said a discussant.
The discussants described old age as the "dusk of man". Those who attained such age are accorded respect and usually appointed as arbiters in family (or communal) disputes and are seen as embodiments of wisdom
Among the women that participated in the FGDs, the recurrent theme was that old age is a gift from God and how you live it similarly comes from Him.
"My old age is God's gift and it is pleasurable. I receive money, food, and clothing regularly from my children. I assist them in taking care of their children too", explained another discussant.
It was generally agreed by the women that there is a difference in the way old men and women are treated and that the former are accorded more respect than the latter, because men occupy the position of headship of the household/family.
Contrary to the above, a discussant expressed that old people are often accused of bewitchment and are frequently blamed or suspected for any evil occurrence within the families, villages or communities. "Such accusations usually start from the younger females," asserted a participant
However, all the respondents agreed that the way old women are treated by family members and the community often depends on individual character; even though there is general respect for the elderly.
When asked about the roles of old men and women in the community; a participant expressed thus:
"Haa, you see, it is the old women you meet at home when no other persons are around, or had passed away. So, it is from old women you can get correct and detailed history of the family, village and community. It is also the old women who will tell you the do's and don'ts in term of the cultural practices of the people".
Respondent's perception of menstruation
When asked why women menstruate every month, a few respondents spoke in an informed manner of shedding of the uterine lining.
"Menses allow women to be able to conceive. It is natural because during the month there is a nest that forms in the womb and if there are sexual relations, the eggs fall out of this nest (Apo) and forms the menses, which flow to get out," explained one respondent.
"When the sperm has not met with the eggs during the fertile period and when the eggs are spoiled they are gotten rid of in the form of blood. This phenomenon happens every month," said another participant.
The respondents, however, spoke of menstruations as representing "dirtiness" within women that has to be expelled from the body. If this "dirtiness" remains inside, it may hamper future conception.
Stated a participant "The importance of the periods is that they get rid of internal dirtiness of the women in order to facilitate fertilization. The bleeding that happens to women each month is for no other reason but because it is the dirtiness that comes out in the form of blood. There is no other method of cleaning out the inside, and the periods play this role".
Perceived causes and consequences of menopause
When the respondents were asked what menopause meant, its causes, and consequences, there was consensus that menopause was part of an aging process. The participants in the FGDs used various phrases to describe menopause in local term. Some of such phrases were "Kolelo agbala moo" [i.e. she can no longer go to the toilet]; "Alejo reetilo" [i.e. her visitor has gone]; "Asiko re ti to" [i.e. her time is up]; and "o tidi okunrin" [i.e. she is now a male].
Some of the participants attributed disease to be a cause of menopause while others believed that it could be caused by witchcraft or sorcery. The most dreaded social consequence of menopause is the risk that a husband may take another wife or obtain a divorce either because he (the husband) fears that he will become ill from having sex with his menopausal wife.
"My husband stopped having an affair with me since my menses stopped. He believes that having sexual intercourse with me may make him contact some diseases," said a discussant.
Some participants however believed that menopause has an advantage in enhancement of religious participation. Several women in all the FGDs noted that with the cessation of menstrual flow they were now free to fulfill their religious obligations more adequately.
"During menstruation, I cannot observe the obligatory prayers and fasting. With the cessation of menses, I am free to participate in all religious activities", said one participant.
Only a few participants thought that the physical consequences of menopause were more significant than their social implications. That physical change could be discussed with husbands or friends who, if they show understanding, could encourage the women to seek treatment.
Many of the stated physical problems of old women are similar and such changes include: generalized body pains, knee pains, insomnia, body weakness, and malaise including internal heat (hot flushes).
Sexual Intercourse after Menopause
Different reactions were expressed to the question on whether women should still have sexual intercourse after menopause, the consensus being that it was an abomination to engage in sexual intercourse after menopause.
"Haaba olorun maje [i.e. May God forbid], I can never have sexual intercourse now. If we engage in sex I will have stomach pains and he will become impotent," stated a discussant.
"Sexual activity after menopause could lead to the death of the woman. It may result in pregnancy called IBU or IJU, (meaning fibroid) or Oyun isale (meaning lower abdominal pregnancy)" stated another.
"There would be an accumulation of sperm in the menopausal woman who engaged in sexual intercourse since there was no menses to flush it out and such an accumulation resulted in loss of weight and watery vaginal discharge" added another participant.
Social Support Networks for Menopausal Women
The adjustment to major changes in anyone's life is easier if there is a strong social support network of friends and family, as well as a self-fulfilling position to occupy in the society. From the FGD, well-educated women are more likely to understand and accept what is happening to them, thereby being more contented with the changes in their bodies.
Among some other women such as Christian groups (Christian Mothers Union), for example Egbe Obirin rere (Good Women's), Egbe Alafia (The Unity Club), and Egbe Ibukun (Blessed Club) were observed to be important in the social lives of older women. Some women belong to dance groups with older women being the leaders. Such groups perform important functions/health tips, not only for women but also for the community.
Some of the social groups named are Egbe Agba ("The Elder's Group"), Egbe Obin Ile (Women's Group), Egbe Alasalatu, (Religion's Group) Egbe Amuludun or Egbe Iyaniwura, (Social Club/Friendship), Egbe Alajeseku (Co-operative Society), Egbe Alabiyamo (Nursing Mothers), etc.
Types of Care and Treatment for Women in Menopause
The way menopause is viewed determines to a significant extent whether or not women seek treatment for menopause-related physical changes. Younger women whose menstrual flow stops prematurely seek assistance, often from traditional or spiritual healers.
"Menopause can be a liberating experience and I know of many menopausal women who are happy and are enjoying it. What you need is an understanding of yourself and strong faith in God," stated a discussant.
"I drank water regularly in order to take off my menopausal problem. Early in the morning, on rising from bed I drink three to four cups of water; it is a habit that helps me to reduce all those problems or complaints of menopause most especially internal heat (hot flushes)", stated a discussant.
"Anywhere I go I never fail to use bitter leaf as a remedy for menopausal problem. I squeeze the fresh leaves in water and drink. Drinking bitter leaf twice daily relieves me of symptoms like hot flashes, internal heat and rheumatism" stated another participant.
"Menopausal women should take plenty of pure honey. Those who take pure honey regularly will remain fresh, healthy and strong till old age. They will also go through menopause without falling victims of symptoms. Mix four desert spoon of honey with ½ glass of water and drink twice daily", stated a participant.
Another useful herbal preparation to ease the symptoms of menopause was described by some of the discussants. The recipe for the tincture included bulbs of garlic and pieces of ginger soaked in dry gin for about two weeks and a spoonful of the concentrate is taken every day, stated a participant.
Some of the participants, however, believed that the secret to living an enjoyable and meaningful life after menopause is to take care of the body early in life.
| Discussion|| |
Menopause is an inevitable part of the aging process and scientists are yet to determine precisely why it occurs.
Majority of the women that participated in this discussion see old age as a stage in a woman's life where she is accorded respect and is seen as an embodiment of wisdom. Older women are seen as custodians of the culture of the community they live in. Most see old age as a gift from God. Even though there is a minority who think that older women are treated badly, still the majority believe that there is a general respect for the elderly in this environment and bad treatment is often the result of individual character.
A few of the respondents had a fairly good idea about why women menstruate. However most of them see menstruation as only means of cleansing the dirtiness in the woman and so it is important that a woman observes her menstruation every month. This shows how important seeing the monthly menses is in this cultural setting. In cultural settings where menstrual bleeding is highly valued as a sign of health and youth, menopausal women may welcome even abnormal bleeding as a sign of continued fertility and thus fail to seek necessary medical care.  However there are cultural settings where it is believed that women become wiser when menstruation ends and thereafter can rise in social status and even assume leadership positions. 
Even though there was generally a positive attitude to aging among the participants, fewer women had a positive response to menopause, which they all agree is a part of normal aging process. This finding seems to contradict other studies, , which found that women, especially the middle-aged and the older ones were positive in their attitudes towards menopause. It is also not in support of the notion that negative attitude towards menopause is least among women who were favorably disposed towards getting older.  Their positive attitude might be a case of beggars having no choice, an attitude that made them view menopausal stage as a fact of life which had to come at its right time and as opportunity for them to meet their religious obligations more regularly and fully as reported in FGD. However, it seems to support the findings of Patterson  and Hunter  that women are generally negative in their attitudes towards menopause.
Sexual intercourse after menopause was viewed as an abominable act by majority of the participants. Any change in sexual activity of women in the climacteric or postmenopausal stage is thought to be more related to their social and psychological state than their physical condition. This is supported by reports from a study which revealed that most of the women experienced no change in sexual desire  and any decrease in sexual desire was more likely to be related to the women's subjective assessment of being climacteric.
Belonging to social groups is one of the adjustment practices made by menopausal women while many engage themselves in business, or revive some interesting activity in which they showed talent, or had some training in their youth before the business of making a home took up all their time.  This is reflected in this study as most of the women belong to one or more social groups. Socially, women belong to one association/group or the other where fun and experiences may likely be created and shared. These offer supports to individual members.
In most cases, it was agreed that when women perceive that the cause of these changes is due to the normal cessation of menstruation, they do not seek treatment, particularly from modern medical services, until the physical complaints get more serious. This is in line with Giwa-Osagie's  submissions that health-seeking practices of most Nigerian women are poor when it comes to health matters irrespective of educational status. Several participants noted that, in the past, herbal treatments were solely relied upon, compared with present day, when some women take advantage of modern alternatives.
Following this extensive discussions by the participants, it could be recommended that there is need for continuous health education on menopause by health workers and the mass media not only for middle-age women but also for other members of the society who would consequently be more emphatic toward their wives, mothers, sisters, aunts, and friends as they go through this life change.
In a related strategy to enhance women's knowledge, attitude, and adjustment practices towards menopause, health workers in health facilities should establish well - women-clinics and social support networks - for women over 40 years to meet regularly to discuss their health problems. In this way, they can share each other's experiences while being advised by medical personnel.
Health workers should recognize their roles as providers of information on important issues of reproductive health including menopause and in the provision of appropriate management of patients with signs and symptoms of menopause. This will help to dispel the myths surrounding menopause.
| Conclusion|| |
From the above discussions, the pattern of behavior displayed is learnt within a cultural, social-economic, and individual context and therefore can be relearned or unlearned, for a new positive behavior can be introduced for both men and women in order to enhance quality of life.
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Department of Obstetrics and Gynecology, University of Ilorin Teaching Hospital, Ilorin, Kwara State
Source of Support: None, Conflict of Interest: None