Women's experiences of menopause: a systematic review protocol of qualitative evidence

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Abstract

Review question/objective

The objective of this review is to identify the meaningfulness/appropriateness of the best evidence regarding how women experience menopause worldwide.

Background

Menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea - the absence of menstruation - for which there is no other obvious pathological or physiological causes. Menopause occurs with the final menstrual period (FMP), which is known with certainty only a year or more after the event.1 The age at menopause ranges between 50 and 51 years, with considerably variability among women living in diverse countries.2,3 In Brazil, mean age for natural menopause is 51.2 years, similar to the developed countries.4

Background

An increase in life expectancy is estimated by the World Health Organization (WHO); they estimate that by the year 2050, there will be one billion women over the age of 60 years.5 Currently, in Brazil, the life expectancy of the female population is estimated to be 72.4 years. In 2007, there were approximately 30 million women in Brazil, with 32% of them aged between 35 and 65 years. Presently, the number of women approaching menopause is increasing and the majority of them are living a greater part of their life in the postmenopausal years.6 This phase of life coincides with other changes in women's lives, requiring adjustments in several dimensions of lifestyle. The main adjustments required are related to healthcare practices, family and marital relations, sexuality and work demanding an open dialogue with family members and partners and other people involved in work relations. The adjustments in lifestyle include the practice of physical and leisure activities, balanced nutrition and more detailed monitoring of one's own health status.7

Background

Although women are living longer, the quality of life of these extra years is not adequate for many women.6 The World Health Organization defines quality of life as the perceptions about the personal positions in the context of culture.5 Such perceptions include: personal values, goals, expectations, standards and concerns.8 In this sense, women's quality of life in menopausal years is influenced by psychosocial and cultural factors, as well as clinical comorbidities or previous emotional difficulties relating to menopause.9

Background

Overall, there is growing evidence that demonstrates menopause as a complex phenomenon, experienced in different ways by women. Factors such as cultural beliefs, values and attitudes towards menopause determine the personal experiences lived in this phase of life.10,11,12

Background

The managers of the Brazilian health system considered the need for reviewing healthcare policies and practices. The recognition of quality of life of women in menopause was considered as a guiding principle.6

Background

For this systematic review, the following definitions will be considered:

Background

Climacteric refers to the aged related transition in women from the reproductive to the non reproductive condition. It is a process rather than a specific point in time. Climacteric is sometimes, but not necessarily always, associated with symptomatology. When symptoms occur, they may be reported as climacteric symptoms.13 Globally, the term menopause is more used than climacteric but, it should be considered that “menopause” is referring to a specific event, the cessation of menses while “climacteric” refers to gradual changes of ovarian function that start before menopause and continue for a while thereafter.14

Background

Premenopause encompasses the entire reproductive period prior to menopause.15 Menopausal transition represents the period of time before the FMP when the menstrual cycle and endocrine changes occur.16 Perimenopause includes the period immediately prior to menopause and the first year after menopause.15 Postmenopause refers to the years after the FMP resulting from natural (spontaneous) or premature menopause.13 Premature menopause refers to women who are aged 39 years or less when menopause first begins. Induced menopause refers to the cessation of menstruation that follows either surgical removal of both ovaries or iatrogenic ablation of ovarian function.16

Background

Menopause is sometimes, but not necessarily always, associated with the appearance of several symptoms. The term “symptoms” refers to perceptions related to changes in the functioning of the body, presented as complaints by individual women. The presence of sporadic symptoms cannot be considered as a strong impact over the woman, is not clinically relevant and does not indicate the need for treatment.17,18 The female's negative social attitudes towards menopause can influence the way in which its symptoms are experienced and, similarly, the way in which menopause is experienced influences women's attitudes towards the menopause symptoms.19,12

Background

The symptoms related to menopause, especially the meanings attributed to this female condition, can vary across cultures.10 Especially in western societies, menopause has been largely considered as a pathology and as a phenomenon associated with negative and long-term consequences on women's health. This vision reflects the lack of specialized literature focusing on the encouragement of quality of life during menopause. Furthermore, there are no precise parameters to compare whether the experience of women living with menopause is within the “normal” range.18

Background

The psychosocial factors modulating the menopausal symptoms, highlighted in scientific literature, influence women's selfcare behaviors.20,21 Although the woman's body is strongly shaped by the reproductive biological cycle, menopause cannot be reduced to only the human physiology. The healthcare providers need to comprehensively assess women living with menopause, taking into account their psychosocial and cultural backgrounds, as well as their personal and subjective perspectives.22

Background

Researchers have found that the current care for women experiencing menopause has not included the provision of comprehensive support, including the need for education on bodily and emotional changes and approaches to selfcare. To change health practices, some authors have assigned the need to develop health promotion actions, focused on the physical, psychosocial and cultural aspects related to menopause.6,23,19 Therefore, the potentialities of health education activities as a successful strategy to promote emancipatory and therapeutic processes towards menopause, through raising their awareness and autonomy regarding attitudes towards health have been addressed.24,25

Background

While essential for provision of the appropriate support to women experiencing menopause, no systematic reviews have been conducted that focus on the experiences of menopause lived by women worldwide. A preliminary search for primary studies focusing on this issue revealed that this topic has been investigated qualitatively by researchers from different countries around the world.

Background

This systematic review will consider the experiences of women during the transition between the reproductive years, through menopause and beyond - women who are living the menopausal transition and women who have reached menopause. Several aspects will also be considered, such as physical, emotional, social and cultural perspectives involving the experiences of menopause. All of the selfcare activities performed to improve wellbeing as well as quality of life, by the women who are living or have lived the experience of menopause will be investigated in this systematic review.

Background

An initial search of the secondary databases was conducted to establish whether a review about the questions in this review has already been conducted. The Joanna Briggs Institute and the Cochrane Library databases were examined to verify whether a systematic review about this theme had previously been conducted or was in progress. Two systematic reviews on the topic of menopause were found, but concerned the experience of symptoms.19,26 It was highlighted that many women view hormone therapy (HT) favorably for symptom relief; although, there are clear hazards associated with long-term HT use. The high value attributed by women to the media as a source of information equivalent to health providers has also been shown. The other one, which examined the relationship between attitudes towards menopause and symptom experience, highlights that women with more negative attitudes towards menopause report more symptoms during the menopausal transition.19

Background

Accordingly, the healthcare professional should consider the current challenge concerning the needs toward the implementation of evidence-based practice (EBP) in menopause related health services. EBP is a process which assembles many steps, considering the best appraised and compiled international evidence as part of the daily decision making of health professionals. This process starts with generating knowledge, followed by the synthesis of the best evidence and concluded when the best evidence is implemented in healthcare.

Background

Developing EBP in health services presumes the association among clinical expertise, background factors involved in the health issues and patients' choices. Today, only a small proportion of healthcare practices are based in evidence.27

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