Experiences and Needs of Perimenopausal Women With Climacteric Symptoms in Singapore: A Qualitative Study

Abstract

Introduction: Women in the perimenopause stage may face climacteric symptoms where physical and mental challenges are experienced. The purpose of this study was to increase the understanding of the experiences and needs of perimenopausal women with climacteric symptoms in Singapore. Method: This is a descriptive qualitative study. Purposive sampling was used to recruit 20 perimenopausal women with climacteric symptoms from a tertiary public hospital in Singapore. Semistructured face-to-face interviews and thematic analysis were used for data collection and analysis, respectively. Results: Participants lacked knowledge resulting in misconceptions of the condition. Experiencing climacteric symptoms led to mixed feelings. The availability of support varied in different sources and forms. Participants seek for more information, understanding, compassion, and empathy from family members and health care professionals. Discussion: Health care professionals should provide adequate support to cater to the diverse experiences and needs of multiracial perimenopausal women with climacteric symptoms. Future research should include the perspectives of health care professionals and family members.

Keywords

climacteric symptoms menopausal symptoms nursing perimenopause multiracial

Introduction

In Singapore, it is estimated that 7.5% of the female population are undergoing perimenopause, with common climacteric symptoms such as hot flushes, insomnia, and lethargy (Loh, Khin, Saw, Lee, & Gu, 2005). Perimenopause is a unique transitory period during the menopause journey, which includes the period immediately prior to menopause and the first year after menopause (World Health Organization, 1994). Perimenopausal women with climacteric symptoms experience amenorrhea coupled with physical and mental manifestations for a period of 3 to 12 months (Loh et al., 2005). Climacteric symptoms experienced during the perimenopause period include vasomotor symptoms such as hot flush and night sweats (Loh et al., 2005); urogenital symptoms such as dryness and irritation of the vagina, painful sexual intercourse, and frequent urinary tract infection (Calleja-Agius & Brincat, 2015); psychological symptoms such as irritability, anxiety, mental exhaustion; and physical symptoms such as sleeping difficulties, muscle and joint pains, and headaches (Rindner, Stromme, Nordeman, Wigren, et al., 2017), which may eventually affect women’s quality of life (Avis et al., 2017).

With an aging population in Singapore, an unprecedented number of women have been and will undergo this phase. Due to the baby boomer generation, there is an increasing number of women undergoing perimenopause. Policies and health care programs related to women’s health are lacking, and educational efforts for women are primarily focused on breast or ovarian cancer (Meng, 2016). Although the latest measures are introduced to enhance health literacy among older women, the focus on menopause among the health care programs remain scarce. A crucial need exists to understand the experiences and needs of perimenopausal women with climacteric symptoms so that they could be better supported.

Background

Previous studies have been conducted on the experiences of perimenopausal women with climacteric symptoms and the factors associated with climacteric symptoms among Western and Asian perimenopausal women (Avis et al., 2009, 2015; Lan et al., 2017). Most of these available studies (Avis et al., 2009, 2015) were conducted in Western contexts, which limits the generalizability of their findings due to cultural differences especially in Asian countries. Gender inequality and discrimination are prevalent in Asian societies, where cultural norms perpetuate the subordinate position of women socially and economically. The suppression of women, and stifling of their sexuality, was deemed as a necessary measure for the development of a civilized society (Baumeister & Twenge, 2002). In patrilineal Asian societies, where females are critical to extending the family lineage, women may feel distress at the loss of their role as valued child-bearers with menopause. For instance, in East Asia, sexuality is often viewed as a taboo due to its strong influence from Confucius and Taoist cultures (Micollier, 2004).

Menopause, which is associated with the sexuality of women (Nosek, Kennedy, & Gudmundsdottir, 2010), is rarely discussed. Majority of the available studies (Avis et al., 2009, 2015; Lan et al., 2017) have examined menopause among women quantitatively, and there is a need of in-depth understanding of the specific needs of Asian perimenopausal women. In particular, the understanding of the unique experiences and needs of multiracial and multireligious Singaporean perimenopausal women with climacteric symptoms has yet to done. Only one local qualitative research among perimenopausal women was found that examined the experiences and needs of only one ethnicity, Chinese perimenopausal women (Lim & Mackey, 2012). Since Singapore is a multiracial country, a representative sample comprising diverse ethnicity is needed to obtain a cohesive understanding of the experiences and needs of Singaporean premenopausal women experiencing climacteric symptoms. The purpose of this study was to increase the understanding of the experiences and needs of perimenopausal women with climacteric symptoms in Singapore.

Method

Design

A qualitative descriptive study design was used in the study. Specifically, a descriptive qualitative design was chosen, as it allows the usage of everyday language to comprehensively summarize an everyday event, from a participant’s perspective (Sandelowski, 2000). As such, everyday events and perspectives from perimenopausal women with climacteric symptoms in Singapore were examined.

Sample and Setting

Participants were recruited from the menopause clinic of an acute tertiary hospital in Singapore between August and November 2017 using the purposive sampling method. Women were eligible to participate in the study if they were able to read, speak, and understand English, were undergoing perimenopause or menopause naturally, and experiencing at least one climacteric symptom. Women who were cognitively impaired or too ill to participate in the face-to-face interviews were excluded. Sample size was based on data saturation, when no new findings emerged. Data saturation was reached at the 18th participant, and two participants were further recruited to confirm the findings.

Data Collection

Audio-recorded interviews were conducted to gain a complete understanding of perimenopausal women’s experiences and needs. Each participant was informed that participation was voluntary and that the interviews would be audio-recorded. Written informed consent was obtained. The face-to-face interviews were semistructured with guiding questions that were developed based on the expert opinions of the coauthors who are experienced nurses in gynecology. The list of probing questions used in the semistructured interviews is presented in Table 1. The interviews ranged between 20 and 39 minutes, with an average of 28 minutes. Demographic information was also collected before the interviews. Significant body language and nonverbal cues that were recorded in the field notes were placed in brackets next to the words that these were spoken with.

Table 1.

Semistructured Interview Guide for Participants.

Probing questions
1. What kind of menopause symptoms do you experience? How do the menopause symptoms affect you?
2. How do you feel about your perimenopause experience with menopause symptoms?
3. How prepared were you for the perimenopause stage of life and the experience of menopause symptoms?
4. Did anyone share with you their experience of perimenopause and menopause symptoms? How did you feel?
5. What are some of your support needs during the perimenopause phase?
6. In what way do you think your perimenopause experience can be improved?
7. Do you see the need of any educational program to assist you better with your perimenopause experience? If yes, what kind?

Data Analysis

Data collection and data analysis were carried out simultaneously. Transcription, coding, and creating themes and subthemes were done manually through the process of thematic analysis (Braun & Clarke, 2006). The coinvestigators analyzed the transcripts independently and any discrepancies were further discussed until a consensus was reached. Themes and subthemes were identified using an inductive method, whereby the themes identified were strongly associated with the data collected (Patton, 1990). Each code was printed onto a slip of paper and read multiple times to identify patterns between the codes. They were then organized into piles that shared a common meaning, thus constituting the subthemes of this study. Participant background information sheets were analyzed using descriptive statistics.

Rigor

Rigor in this study was maintained through credibility, confirmability, dependability, transferability, and authenticity (Patton, 1990). Data analysis was performed independently by the co-investigators, and any discrepancies were discussed until a consensus was reached. This process ensured the credibility and confirmability of the findings. An audit trail was maintained throughout the research process to ensure dependability. The provision of the study setting, data collection, and the analysis processes will allow readers to critically evaluate the transferability of the study’s findings. Participants’ original quotes, with colloquial language, were presented to ensure authenticity.

Ethical Considerations

This study was approved by the Centralized Institutional Review Board on August 5, 2017, before the commencement of the study. The three ethical principals in the Belmont Report (respect for human dignity, beneficence, and justice) were employed in this study. The participants were thoroughly briefed on the purpose and details of the study before consent was obtained. Participation was voluntary, and the participants were informed of their rights to withdraw at any point of the study. Confidentiality was strictly adhered to throughout the study.

Results

Description of the Study Participants

A total of 20 perimenopausal women with diverse ethnicity were included in this study. The participants were aged between 47 and 54 years, and the majority were Chinese, followed by Indians, Malays, and other ethnicities. The participants had varying financial backgrounds, with monthly household incomes ranging from less than SGD$1,000 to above SGD$5,000. The women were generally healthy and they visited menopause clinic for their climacteric symptoms. Table 2 details the demographics of the participants.

Table 2.

Demographics of the Participants.

Characteristics	Participants (N = 20)	Percentage
Age
Mean (SD)	50.95 (1.73)
Range	47-54
Ethnicity, n (%)
Chinese	12	60
Malay	3	15
Indian	4	20
Others	1	5
Nationality, n (%)
Singaporean	18	90
Singapore permanent resident	2	10
Religion, n (%)
Buddhism	6	30
Christianity	5	25
Hinduism	3	15
Islam	3	15
None	3	15
Highest level of education, n (%)
Secondary	8	40
Tertiary	9	45
University degree and above	3	15
Financial difficulty, n (%)
Yes	4	20
No	16	80
Climacteric symptoms, n (%)
Hot flushes	18	90
Insomnia	14	70
Mood changes	15	75
Skin dryness	15	75
Muscle and joint pains	13	65
Headache	11	55
Vaginal dryness	13	65
Loss in sexual interest	11	55
Heart palpitation	3	15
Treatment, n (%)
No treatment	14	70
Hormone therapy	1	5
Traditional Chinese medicine	4	20
Others	1	5
Monthly household income, n (%)
Below S$1,000	1	5
Between S$1,000 and S$3,000	5	25
Between S$3,001 and S$5,000	4	20
Above S$5,001	10	50
Marital status, n (%)
Married	15	75
Divorced/separated	3	15
Single	2	10
Number of children, n (%)
None	4	20
1	4	20
2 and above	12	60
Living conditions, n (%)
Staying alone	3	15
With family	17	85
Primary caregiver, n (%)
Yes	7	35
No	13	65
Any other medical conditions n (%)
Yes^a	3	15
No	17	85

Note. SD = standard deviation; S$ = Singapore dollar.

Diabetes, migraines, hypertension.

Themes

Five themes emerged from the data analysis: (1) uncertainty and misconceptions, (2) changes in the body, (3) mixed feelings, (4) social support, and (5) “wish” list of women. The themes and subthemes are presented in Table 3.

Table 3.

Themes and Subthemes.

Themes	Subthemes
Uncertainty and misconceptions	• Uncertainty of symptoms, treatment options, and health consequences • Misconceptions regarding perimenopause and climacteric symptoms
Changes in the body	• Physical symptoms • Sexual experiences • Psychological symptoms
Mixed feelings	• Giving back to the younger generation • Sense of ownership • Feelings of being lost • Loss of womanhood • Aging and death
Social support	• Sources of support • Support for working women
“Wish” list of women	• Availability of information • Understanding and compassion • Empathetic health care professionals

Uncertainty and Misconceptions

Perimenopausal women with climacteric symptoms in this study seemed to be surrounded by a cloud of uncertainty. Many had doubts regarding their symptoms, their management, health consequences, and treatment options.

Uncertainty of Symptoms, Treatment Options, and Health Consequences

Women were unsure if their climacteric symptoms were occurring physically or psychologically. There was doubt as to whether these symptoms were menopause-related, lifestyle-related, or weather-related and if they indicated underlying health problems. Uncertainty of treatment options stemmed from the fear of treatments causing other health-related problems such as cancer.

They [family and friends] say it is best not to take the (pause) hormone pills. Because it will cause (pause) ovaries cancer. (P09)

Misconceptions Regarding Menopause and Climacteric Symptoms

Despite being more educated than the general population, these women had numerous misconceptions regarding menopause and climacteric symptoms. Some women saw menopause and the accompanying climacteric symptoms as a type of sickness, while many of them also had misconceptions regarding the onset of menopause.

My mother had these symptoms and then died of cancer. I am also having so many problems (symptoms) . . . (I am) scared (that I) will die of cancer too. (P04)

Actually, I got my menses when I was very young, like ten, eleven years old. So, I thought I’ll get it [menopause] earlier, like in my late 30’s, but it didn’t happen until now. (P03)

Changes in the Body

Most perimenopausal women experienced physical symptoms. Changes in libido hinged on one’s stage of perimenopause and the effects were dependent on the dynamics between her and her partner.

Physical Symptoms

Almost all the perimenopausal women in this study experienced physical symptoms. Hot flushes were the most commonly reported physical symptom, which disrupted the participants’ daily lives and caused insomnia. Frequent headaches and fatigue and exhaustion due to poor sleep also impaired their daily functioning and desire to work.

The problem is that if you don’t get a good night’s rest, you are not alert in the morning. . . . You’re not able to contribute to the level you have been (sigh) because you’re tired all the time, ya. (P16)

Sexual Experiences

Women in the late perimenopause stage tend to experience lower libido, vaginal dryness, and painful intercourse compared with women in the early stage. There was a divergence on these women’s opinions of fulfilling their husbands’ sexual needs as the duty of a wife. There were a number of women who had stopped sexual intercourse completely.

Now, I have, uh, less [sexual] desire. So, I feel that I can’t fulfil my job as a wife. (P19)

Psychological Symptoms

Discomfort from physical symptoms and mood swings heightened women’s general sense of irritability. This placed a strain on their relationships with loved ones and in their workplaces. There were often unexpected times when they lost their tempers.

It affects my mood. I feel very irritated. It’s, like, sometimes, my children ask me questions, I also feel so irritated to answer them back. (P17)

Mixed Feelings

Some women felt pride in giving back to the younger generation and taking ownership of their perimenopause journeys, but some also felt lost and alone during their journeys. Their notions of womanhood were threatened, and their sense of aging and impending death increased.

Giving Back to the Younger Generation

Many women felt an innate responsibility to share their knowledge and experiences with the younger generation to increase their awareness and preparedness for their future menopause and its associated symptoms.

When I tried to share with them [younger staff] [about] my experience now, going through menopause, they are thankful. (P02)

Sense of Ownership

Women found a sense of pride in owning this phase of life by preparing and enhancing self-awareness through speaking to those with prior experience. Some women employed positive self-talk to maintain positivity throughout this period.

Because I know that, all women have to go through this. . . . I did mentally prepare myself. . . . I did read up quite a lot. (P02)

Feelings of Being Lost

The sense of being lost was crippling for some women. It left them as a fraction of who they were, causing them to isolate themselves. In addition, their cultural backgrounds exacerbated their sense of being alone. Especially Muslim women were reluctant to share their experiences openly.

I come from a generation and religion that doesn’t talk about these things [menopause]. This is something we have to endure. (P16)

Loss of Womanhood

Some women pegged their sense of womanhood on the presence of their monthly menstruation. Others associated it with their sexual abilities to fulfil their husband; thus, a decrease in libido led to a decrease in their sense of being a woman.

Yes, it’s terrible (cries). I am no longer a woman. . . . I feel like telling him [husband], “Go and get another wife. Because I can’t fulfil my job as a wife.” (P02)

Aging and Death

The stage of perimenopause with climacteric symptoms was seen as a time of growing old and moving closer to death. As shared by one participant:

I wouldn’t say prepared, but you slowly slip into it. Ya, it’s like age, I guess, you know you will eventually [die]. It’s a non-negotiable. (P18)

Social Support

Support for perimenopausal women with climacteric symptoms was important as it allayed the anxiety experienced by them. All the participants received support; however, the source and amount varied from participant to participant.

Sources of Support

Sources of support varied for the women. Female family members were the most available source of support for some women but not for others. Similarly, some found support from their friends, while others sought informational support online.

My mum is [an obstetrician], but she never taught me (shakes head). . . . So, everything I learn, I make much, much more mistakes. It’s not good. (P19)

I found information from the internet, but (I was) wary of fake news, so I asked around for good websites. (P08)

Support for Working Women

In their workplaces, some women received good support from their employers, while others felt constricted by the nature of their work due to the gender bias placed against them. While women hoped for better support, they did not expect it given the nature of Singapore’s busy lifestyle.

If you’re in a male-dominated industry, they tend to, every time you have a bit of a showdown or an attitude or whatever, they tend to say menopausal or whatever. That labelling. (P18)

“Wish” List of Women

Perimenopausal women with climacteric symptoms had “wish” lists that they hoped could be fulfilled, such as having more informational support, more understanding from peers and family, and empathy from health care professionals.

Availability of Information

Many women desired for more information on the symptoms, consequences, and physiology of menopause and hormone therapy to be better prepared.

Have to teach us to prepare [for menopause]. Just have to teach us where to find the help, ya. More focus on how to have a quality of life during menopause. (P19)

Understanding and Compassion

Women longed for understanding and compassion from the people around them, especially from family members and in their workplaces.

I wish for support at home. Especially from my son (sighs and dabs tears), right. . . . When you just started to feel alone, I want to feel [that] there are people to show me the concern. (P04)

I mean, my head [of department] is also a woman, so I thought maybe (pause), ya, she could be more understanding . . . or more sensitivity or, ya, a bit of care might help, la. (P08)

Empathetic Health Care Professionals

These women who were in the perimenopause stage and were undergoing climacteric symptoms desired for more sensitivity and individualized care from health care professionals.

Be more attentive, be more delicate to us (sniffles) because we are the ones who need support, the ones that are actually going through [menopause]. (P06)

Discussion

This study explored the experiences and needs of perimenopausal women with climacteric symptoms in Singapore. All races were included in the study, with Chinese being the major ethnicity as per Singapore’s demographic profile (Department of Statistics Singapore, 2018). This study revealed that experiencing climacteric symptoms during the perimenopause stage brought about much uncertainty about the symptoms faced, their management, treatment options, and health consequences. While research on menopause has been gaining traction in the recent years, women are still concerned about what to expect during menopause, the accompanying climacteric symptoms, and the physiology of both menopause and its symptoms (Bowes, Stevenson, Ahluwalia, & Murray, 2012). This may be due to the variation in bodily changes and experiences from woman to woman and the unpredictability of present and future symptoms (Hvas & Gannik, 2008). Similar to our findings, numerous misconceptions regarding menopause and the accompanying climacteric symptoms were also found in a previous study (Feeley & Pyne, 1975).

Hot flushes were the most commonly experienced symptom, which corresponds to preexisting literature (Lan et al., 2017; Lim & Mackey, 2012; Loh et al., 2005). Likewise, sleep difficulties were also reported in a previous study (Rindner, Stromme, Nordeman, Hange, et al., 2017). This could be due to changes in the circadian rhythm, affecting women’s sleep–wake cycles, and the low levels of melatonin (Jehan et al., 2017). The disruptive nature of hot flushes and night sweats impairs sleep, causes fatigue, and reduces daytime productiveness (Ayers & Hunter, 2013). Similar to previous study, urogenital symptoms such as vaginal dryness and lack of libido were experienced by the women interviewed in this study (Nelson, 2008). These experiences were found to be caused by decreasing estrogen and androgen levels and often affected intimate relationships between perimenopausal women and their partners (Nelson, 2008).

Women in this study had mixed feelings toward their perimenopause climacteric symptoms. This is in line with the current literature in which menopause is seen as a time of contradiction and change, when mixed emotions are aplenty, interplaying with one another (Hoga, Rodolpho, Goncalves, & Quirino, 2015). Positive feelings in this study came from feelings of giving back to the younger generation and sense of ownership to these women’s menopausal experiences. As these perimenopausal women were about to complete all stages of femininity, from menarche to menopause, it placed them in a better position to share their experiences with those who were younger (Cifcili, Akman, Demirkol, Unalan, & Vermeire, 2009).

Women in this study felt lost as their climacteric symptoms made it difficult for them to lead their usual lives, and they were unsure if the women around them experienced the same symptoms. This is consistent with the current literature in which, despite sharing their experiences with other women, perimenopausal women felt a deep sense of isolation, which led to some women questioning their sanity (Hyde, Nee, Howlett, Drennan, & Butler, 2010). While some women had older women to share their experiences with, others felt that people of their generation did not talk about menopause (Hoga et al., 2015). This could be due to the intrinsic link between menopause and sexuality, a taboo topic in Asian culture (Micollier, 2004). While this taboo is slowly losing traction, some older women found this ingrained in themselves and were thus unable to share their wisdom with those currently experiencing perimenopause climacteric symptoms (Utz, 2011).

As the identity of womanhood is strongly associated with menstruation, the gradual cessation of menstruation during the perimenopause period threatens a woman’s identity of womanhood (Hoga et al., 2015). In addition, a deep-seated patriarchal society has resulted in women pegging their womanhood to their sexual prowess and abilities to fulfil men’s sexual needs (Hoga et al., 2015). This could be the reason the women in this study felt that their identities of being a woman were shaken during perimenopause with low libido, vaginal dryness, and the cessation of menstruation. The sense of aging and death was also common among the women in this study and previous studies (Hoga et al., 2015; Mackey, Teo, Dramusic, Lee, & Boughton, 2014). These women associated menopause with growing old and contracting diseases such as osteoporosis and cancer. Furthermore, the association of reaching menopause and impending death seems to be unique in Singapore and had been echoed in a previous Singapore-based study (Mackey et al., 2014). Western literature has reported that women yielded more positive attitudes and were appreciative of living long enough to experience menopause (Sommer et al., 1999). In fact, age was associated with wisdom and knowledge (Im, Lee, & Chee, 2010). Thus, culturally specific attention needs to be provided to women from different ethnic backgrounds.

The various degrees of support received and “wished for” by women in this study through self-help methods and from the people around them is supported by literature (Mahadeen, Halabi, & Callister, 2008). Informational support was commonly sought online, but the unprecedented amounts of online information, the lack of critical analysis, and the lack of tailoring to one’s medical condition brought about unnecessary worry for women (Ahluwalia, Murray, Stevenson, Kerr, & Burns, 2010). Informational support through education could therefore be crucial in enhancing self-management capacity and developing the resources women have on hand.

Family support has been found to decrease menopause-related stress (Cifcili et al., 2009). However, women often felt misunderstood as their vulnerabilities in sharing were met with doubt and belittlement by their spouses and younger family members (Hoga et al., 2015). A study showing women’s preference for “quiet support” (Im, Lee, & Chee, 2011) was echoed in this study, whereby women appreciated it when their husbands spent additional time with them. The Asian culture could be a reason why such actions were favored over words since Asians are generally more stoic and less expressive of their emotions than Westerners (Micollier, 2004). For minority women, the extended family, church community, and involvement in other external social organizations are also vital sources of support (Rice, 2005). Comparable with this study, previous studies have reported participants seeking more empathetic support from health care professionals (Hyde et al., 2010). Given that women spend close to a third of their lives traversing through their menopause journeys, understanding and support from those around them are of utmost importance.

Unique to this study is the inclusion of women from different races in proportion to that of Singapore’s population, which allows for a holistic perspective of the experiences and needs of perimenopausal women with climacteric symptoms. However, the single-site study design and the inclusion of only English-speaking participants could have resulted in an underrepresentation of actual women undergoing perimenopause in Singapore. Therefore, future qualitative studies can consider including non-English-speaking perimenopausal women. Future longitudinal mixed methods studies can also be conducted to analyze trends with regard to the stages of menopause and climacteric symptoms. Last, a triangulation of findings by assessing the perceptions of health care professionals and family members regarding perimenopause climacteric symptoms will provide a holistic view on the phenomenon of interest.

Conclusion

The results from this study highlight the experiences and needs of perimenopausal women in Singapore. This study revealed that health care professionals should develop individualized culturally specific educational programs to meet the changing needs of perimenopausal women. The current clinical guidelines on managing perimenopausal women with climacteric symptoms can be improved by taking into account the culturally specific needs of perimenopausal women. Further qualitative research can be conducted to examine health care professionals’ and family members’ perceptions of perimenopause climacteric symptoms in Singapore.

Footnotes

Acknowledgements

The authors would like to thank the Publications Support Unit of National University of Singapore, for assistance in the language editing of this article.

Author Contributions

Study design: SS

Data collection: DSPO and MTC

Data analysis: SS and MTC

Manuscript writing: SS and DSPO

Critical review of the manuscript: SS, DSPO, and MTC

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Shefaly Shorey

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